CT vs vascular

[Mbappé]

I’ve been torn between vascular and CT for a while. I love vascular in general and would like to operate on blood vessels, regardless of the anatomical regions.

The tie-breaker would be the open surgeries, I guess. My questions are as follows;

1.) What’s the bread and butter open surgery cases for a typical community, private-practice vascular/CT surg? I know CABGs are still pretty common in community settings, but what about big whacks like open AVRs? Open AAA repairs? Peripheral artery bypasses? Carotid endarterectomies?

2.) With the rapid development of endovascular techniques, is it possible for one to have open vascular surgery dominated practice? I'm not talking about, like, 90:10 ratio for open:endo cases;
60:40 or even 50:50 would probably be enough for me.
Anything less than that is just too much; might as well try my luck at IR.

3.) At my place, the CT residents either focus on cardiac or thoracic surg. Those on cardiac-heavy track train pretty extensively on endovascular skills. This is common I assume? Do CT surgeons do high-end endovascular procedures like TEVAR in the community settings?

4.) Between PP vascular and CT surg, which surgical specialty leans more towards open surgeries?
What about academics?

I know a lot of these questions have been asked before, but I feel the answers were little bit outdated given how vascular and CT surg practice have drastically changed over the years.
Thank you

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[TypeADissection]

Alright, I'll take the bait and go first. Then let some of the more seasoned and knowledgeable posters reaffirm, clarify or debunk some of my statements if I'm in error. I think ThoracicGuy and JolieSouth will be able to add a lot more stuff.

1.) What’s the bread and butter open surgery cases for a typical community, private-practice vascular/CT surg? I know CABGs are still pretty common in community settings, but what about big whacks like open AVRs? Open AAA repairs? Peripheral artery bypasses? Carotid endarterectomies?
- Take a look at what's going on in CTS with the TAVR vs SAVR and SurTAVI trials. I think eventually, based on non-inferiority, TAVR will come to dominate a lot of the aortic valves that need to be fixed except for the youngest and "healthiest" of patients who can tolerate open repair. Depending on your training program and the politics of the hospital, it may be you doing them or IC. With cards controlling the patient population, you may be asked to provide back-up or trans-apical approaches if they can't there via fem. At my institution, IC does more TAVRs than CTS. Carotids are the gallbladders of vascular surgery. We do a lot of them here and they're great operations, as long as you don't think about what you can do to an asymptomatic patient... We also do a fair amount of bypasses: infrainguinal and aorta-iliac. But the bread and butter of our service is angios, fistulas, stank feet and EVARs.

2.) With the rapid development of endovascular techniques, is it possible for one to have open vascular surgery dominated practice? I'm not talking about, like, 90:10 ratio for open:endo cases; 60:40 or even 50:50 would probably be enough for me. Anything less than that is just too much; might as well try my luck at IR.
- It is definitely possible to have an open practice but it'll depend on the situation you're in. Do you have partners feeding you open cases? How is your reimbursement setup? I'd say that here each guy is about 60:40 endo to open and it varies month to month. We've had months where we did a chunk of open AAAs, aorto-bifems, and such; then all of a sudden we're just pounding out angios, AVFs, and chopping off little piggies into buckets.

3.) At my place, the CT residents either focus on cardiac or thoracic surg. Those on cardiac-heavy track train pretty extensively on endovascular skills. This is common I assume? Do CT surgeons do high-end endovascular procedures like TEVAR in the community settings?
- I'll let ThoracicGuy or someone else comment on this. A lot of this has been covered in previous threads. Hint: search button is a helpful tool. I will say though that vascular does all the TEVARs here for trauma or aneurysms.

4.) Between PP vascular and CT surg, which surgical specialty leans more towards open surgeries? What about academics?
- Hard to say because everything is situation dependent. There will always be a need for open surgery and from a training standpoint, it's critical for us coming through the ranks to have a strong open skill set. My buddy just started his first week as an attending vascular surgeon and he had some big open whomps to start with his senior partners.

And since I'm throwing my 2 Abe Lincolns in there, the tie-breaker for you actually isn't the volume of open surgery. It really isn't. CTS and vascular may sing similar hymns but practice their religion in different churches. You have to spend some time on a CTS service and get the calls about sick patients on LVADs and ECMO. You have to get paged about an esophagectomy in the ICU that is getting septic. You have to be ready to head out the door for home only to find out that there's a thrombosed AVG in the ED that needs a de-clot. It's the personality of the fields and the types of patients in them and the kind of work that you're going to have to do to take care of them that will determine which one you end up choosing. Hope this helped. Cheers.

 

[Mbappé]

Alright, I'll take the bait and go first. Then let some of the more seasoned and knowledgeable posters reaffirm, clarify or debunk some of my statements if I'm in error. I think ThoracicGuy and JolieSouth will be able to add a lot more stuff.

1.) What’s the bread and butter open surgery cases for a typical community, private-practice vascular/CT surg? I know CABGs are still pretty common in community settings, but what about big whacks like open AVRs? Open AAA repairs? Peripheral artery bypasses? Carotid endarterectomies?
- Take a look at what's going on in CTS with the TAVR vs SAVR and SurTAVI trials. I think eventually, based on non-inferiority, TAVR will come to dominate a lot of the aortic valves that need to be fixed except for the youngest and "healthiest" of patients who can tolerate open repair. Depending on your training program and the politics of the hospital, it may be you doing them or IC. With cards controlling the patient population, you may be asked to provide back-up or trans-apical approaches if they can't there via fem. At my institution, IC does more TAVRs than CTS. Carotids are the gallbladders of vascular surgery. We do a lot of them here and they're great operations, as long as you don't think about what you can do to an asymptomatic patient... We also do a fair amount of bypasses: infrainguinal and aorta-iliac. But the bread and butter of our service is angios, fistulas, stank feet and EVARs.

2.) With the rapid development of endovascular techniques, is it possible for one to have open vascular surgery dominated practice? I'm not talking about, like, 90:10 ratio for open:endo cases; 60:40 or even 50:50 would probably be enough for me. Anything less than that is just too much; might as well try my luck at IR.
- It is definitely possible to have an open practice but it'll depend on the situation you're in. Do you have partners feeding you open cases? How is your reimbursement setup? I'd say that here each guy is about 60:40 endo to open and it varies month to month. We've had months where we did a chunk of open AAAs, aorto-bifems, and such; then all of a sudden we're just pounding out angios, AVFs, and chopping off little piggies into buckets.

3.) At my place, the CT residents either focus on cardiac or thoracic surg. Those on cardiac-heavy track train pretty extensively on endovascular skills. This is common I assume? Do CT surgeons do high-end endovascular procedures like TEVAR in the community settings?
- I'll let ThoracicGuy or someone else comment on this. A lot of this has been covered in previous threads. Hint: search button is a helpful tool. I will say though that vascular does all the TEVARs here for trauma or aneurysms.

4.) Between PP vascular and CT surg, which surgical specialty leans more towards open surgeries? What about academics?
- Hard to say because everything is situation dependent. There will always be a need for open surgery and from a training standpoint, it's critical for us coming through the ranks to have a strong open skill set. My buddy just started his first week as an attending vascular surgeon and he had some big open whomps to start with his senior partners.

And since I'm throwing my 2 Abe Lincolns in there, the tie-breaker for you actually isn't the volume of open surgery. It really isn't. CTS and vascular may sing similar hymns but practice their religion in different churches. You have to spend some time on a CTS service and get the calls about sick patients on LVADs and ECMO. You have to get paged about an esophagectomy in the ICU that is getting septic. You have to be ready to head out the door for home only to find out that there's a thrombosed AVG in the ED that needs a de-clot. It's the personality of the fields and the types of patients in them and the kind of work that you're going to have to do to take care of them that will determine which one you end up choosing. Hope this helped. Cheers.

That was very helpful. Thank you very much.
I've also searched this forum about TAAs and TEVARs. You're right, they were discussed quite recently on this subforum.

I thought I'm gonna share this too.
Yesterday I had this discussion with a CT (thoracic) surgery resident regarding CT and endovascular surgery. Basically, he shared the same view as you. He said that cardiac surgery had missed the endovascular boat and, although many integrated CT residencies have now incorporated endovascular training into their programmes, in practice, cardiologists control the patient flow so at this point it might be a little bit too late for surgeons to take back valve/TAA/coronary/whatever cases that have fallen to the interventional crowds.
Regarding TAVR, he said that plenty of alternatives to femoral access are currently being explored (transcaval, transcarotid, trans-subclavian), aside from the obvious transthoracic approaches, squeezing cardiac surgeons' position even further.
I've also found an interesting commentary on the future of CT surgery. It doesn't tell much, but I think it's interesting because it's a perspective coming from an official society of thoracic surgeons. It's in French though..
Société Française de Chirurgie Thoracique et Cardio-Vasculaire

After talking to thoracic resident and reading your answer here, I'm leaning towards vascular surgery. I haven't yet talked to any vascular surgery resident at my school, but I hope I'll be able to soon.
Thanks!

 

[dienekes88]

I’ve been torn between vascular and CT for a while. I love vascular in general and would like to operate on blood vessels, regardless of the anatomical regions.

The tie-breaker would be the open surgeries, I guess. My questions are as follows;

If this is the case, it sounds like you should do cardiothoracic surgery.

1.) What’s the bread and butter open surgery cases for a typical community, private-practice vascular/CT surg? I know CABGs are still pretty common in community settings, but what about big whacks like open AVRs? Open AAA repairs? Peripheral artery bypasses? Carotid endarterectomies?

Open AVRs aren't really "big whacks." They're a very routine operation that is rapidly being overtaken by TAVR. Having said that, TAVR is contraindicated in bicuspid aortic valve and aortic insufficiency. While this is a subset of all of the aortic valve disease out there, it's something to keep in mind.

2.) With the rapid development of endovascular techniques, is it possible for one to have open vascular surgery dominated practice? I'm not talking about, like, 90:10 ratio for open:endo cases;
60:40 or even 50:50 would probably be enough for me.
Anything less than that is just too much; might as well try my luck at IR.

You would probably have to be somewhere where you're the primary referral guy (county hospital system, VA, or community hospital with limited competition). Being able to do a lot of this stuff endovascularly is a definite selling point. Patients want these procedures done over a wire.

3.) At my place, the CT residents either focus on cardiac or thoracic surg. Those on cardiac-heavy track train pretty extensively on endovascular skills. This is common I assume? Do CT surgeons do high-end endovascular procedures like TEVAR in the community settings?

Not super common. A lot of CT folks finish with limited endo skills. You have to go out there and get the skills for more advanced stuff if you want it.

Having said that... To be quite honest, TEVAR isn't really "high-end." Most young community cardiac surgeons should be able to do these. Having said that, the referrals often go to vascular surgery. EVAR is much more difficult, because you have to think about angulated necks, thrombus, conicity, suprarenal fixation...

4.) Between PP vascular and CT surg, which surgical specialty leans more towards open surgeries?
What about academics?

I know a lot of these questions have been asked before, but I feel the answers were little bit outdated given how vascular and CT surg practice have drastically changed over the years.
Thank you

CT Surgery is mostly open. It's rare to have a significant endovascular component... If you go out and get the transcatheter aortic valve replacement experience, then you can take part in them (tradeoff crossing the valve, deploying the device, etc.). It'd be somewhat unusual for you to be doing TAVRs on your own as a cardiac surgeon.

Vascular these days seems to be a ton of endovascular work. There's still a role for open, but endovascular skills are absolutely critical to being relevant in today's job market and to keep up with the standard of care.

 

[Mbappé]

Thank you for your input, @dienekes88. I've read your posts in other similar threads and always found yours really helpful.
Regarding vascular surgery, indeed, one vascular surgery resident at my school admits that they are exposed to significant amount of endovascular surgery during their training. This is definitely nothing new.

Just as you said, endovascular skills are essential for any surgeons operating on blood vessels. I imagine it'd probably be very beneficial for a cardiac surgeon to possess such skills. It's unfortunate that CT surgery as a field missed the opportunity to incorporate endovascular surgery into its practice earlier.
I think I've pretty much decided on what I want to do. I'd like to be a cardiac surgeon who does primarily CABGs and open heart surgeries. However, I'd try to gun for integrated vascular surgery residency first in order to get proper endovascular training and add wire skills to my "armamentarium" (always loved that word), getting the best of both worlds. Per ABTS, I figured it is possible for one to enter CT surgery training after completing integrated vascular surgery residency. Though I'm not sure how common this is.
American Board of Thoracic Surgery

 

[ThoracicGuy]

Thank you for your input, @dienekes88. I've read your posts in other similar threads and always found yours really helpful.
Regarding vascular surgery, indeed, one vascular surgery resident at my school admits that they are exposed to significant amount of endovascular surgery during their training. This is definitely nothing new.

Just as you said, endovascular skills are essential for any surgeons operating on blood vessels. I imagine it'd probably be very beneficial for a cardiac surgeon to possess such skills. It's unfortunate that CT surgery as a field missed the opportunity to incorporate endovascular surgery into its practice earlier.
I think I've pretty much decided on what I want to do. I'd like to be a cardiac surgeon who does primarily CABGs and open heart surgeries. However, I'd try to gun for integrated vascular surgery residency first in order to get proper endovascular training and add wire skills to my "armamentarium" (always loved that word), getting the best of both worlds. Per ABTS, I figured it is possible for one to enter CT surgery training after completing integrated vascular surgery residency. Though I'm not sure how common this is.
American Board of Thoracic Surgery

It's possible, but not likely to go through a vascular training and then go into ct. You'll not really want to add 2-3 years onto your training by that point when you could just go practice as a vascular surgeon.

 

[TypeADissection]

If your primary goal is to do bread and butter heart stuff, I think the better way to go would be through an I-6 CTS or traditional CTS fellowship after general surgery. Afterwards, there are 1-year fellowships focused on TAVRs and other endovascular arch stuff that is much more applicable to your practice. Tinkering with fistulas, managing foot wounds and the like can be onerous if you have zero intention of ever doing that down the road.

We're becoming more specialized in medicine today and I personally would rather spend my time doing the thing I actually want to do, rather than using a purely independent specialty as a bridge to something else. It's just too painful. But maybe you like pain? Just make sure you have a safe word...

 

[Mbappé]

It's possible, but not likely to go through a vascular training and then go into ct. You'll not really want to add 2-3 years onto your training by that point when you could just go practice as a vascular surgeon.

If your primary goal is to do bread and butter heart stuff, I think the better way to go would be through an I-6 CTS or traditional CTS fellowship after general surgery. Afterwards, there are 1-year fellowships focused on TAVRs and other endovascular arch stuff that is much more applicable to your practice.

Thanks y'all for the advices. I'll definitely take a look at integrated CT surgery residency. After all, there are some I6 cardiac surgery programmes like my school's that seem to provide a fair amount of endovascular experience, though I reckon it's nothing compared to what you get during proper vascular surgery training. Then again, my end goal is to do open heart/thoracic aortic stuffs so endovascular training might or might not be that relevant to my future practice.

... Tinkering with fistulas, managing foot wounds and the like can be onerous if you have zero intention of ever doing that down the road.

We're becoming more specialized in medicine today and I personally would rather spend my time doing the thing I actually want to do, rather than using a purely independent specialty as a bridge to something else. It's just too painful. But maybe you like pain? Just make sure you have a safe word...

Well, my favourite procedure is off-pump CABG and I'd like it to be the bread-and-butter and comprise a significant component of what I do in my future practice. On the contrary, however, I do enjoy vascular procedures, though I'd admit that my exposure to vascular surgery has been somewhat lacking. While definitely not one of those vascular big-whacks I'm looking for, A-V fistula is still an 'open' surgery in my book and I find it pretty enjoyable (or tolerable?). I also enjoy scrubbing in open lower extremity revascularisation cases like aorto-bifem, fem-pop, and below-the-knee bypasses. I do f***ing hate amputations, but I think I can tolerate them. Chronic foot wound care? Well, CT has this postoperative mediastinitis thing, which I find somewhat analogous haha .
I fully understand your point though. I agree that pursuing I6 cardiac surgery residency is way more convenient and relevant to my goals.