Life as a vascular surgeon

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SpikesnSpookes

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Hi all,

If anyone has any details, I'd be interested in learning about what the life of a vascular surgeon is like. Other than aortic aneurysm repair, are there any procedures that offer as much excitement? As a rotating 3rd year, you hear rumors about each specialty and the one associated with vascular is that the procedures are generally very boring. Was hoping someone can shed light on this!

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I did a vascular rotation by chance my 3rd year, and I loved it so much I did a 2nd one in my 4th year of med school. I'd like to end up applying for a fellowship for it (assuming i get accepted into a gen surg residency). I thought it was an incredibly cool rotation though. In 2 months, I saw a ton of TEVAR/EVARs, 3 open AAA cases, some bypasses, lots of stents and angioplasties, a few enarterectomies, and some access procedures. My rotations were limited to the private university hospital so that's probably why I saw as much aneurysm repairs as I did. The county hospital still had their fair shares, but they did do a ton more access procedures. I thought all of them were neat. Even the angioplasties. there's something therapeutic about watching the dye flow past a blockage that was opened up.

As far as life goes, the fellow looked like death every day. There were days where transfers came in from out of the state or patients came into the ED with a ruptured AAA or with critical limb ischemia, and the cases started in the afternoon and didn't get out till way late at night. And guess what, everyone comes into work the next day. I talked with him about it a lot cause he was a really nice guy, and he said that as a fellow, his life is incredibly rough. There are only 3 fellows at our program, and so they split up call evenly between 4 hospitals. He says he doesn't see his wife much, and he spends his nights at the hospital kinda often.. That being said, he loved the field. He loved the patients. He just put on a smile on his face and dealt with it cause it's what he's passionate about. The attendings seemed to have a pretty decent life though, much better than the fellow, but that's kinda how it always is.

I'm sure other residents/fellows/attendings can offer better insight since my experience is very limited.
 
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Hi all,

If anyone has any details, I'd be interested in learning about what the life of a vascular surgeon is like. Other than aortic aneurysm repair, are there any procedures that offer as much excitement? As a rotating 3rd year, you hear rumors about each specialty and the one associated with vascular is that the procedures are generally very boring. Was hoping someone can shed light on this!

As an attending, we don't often want the "exciting" cases that med students and residents want to be in. I sure don't mind some nice, boring cases...
 
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As an attending, we don't often want the "exciting" cases that med students and residents want to be in. I sure don't mind some nice, boring cases...
He/she will understand the joke when grown-up!
 
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I love big surgeries just as much as anyone here. It's amazing what some years in a general surgery residency will do to your perspective. As a med student, I'd see a day of gallbladders and hernias and think, "Aw man. Where are the big cases?" Now as a PGY-4, I see a day of gallbladders and hernias and think, "This is going to be a great great day." For whatever crazy reason, I will be applying to vascular surgery this year. The life will be rough, but I find the wide breadth of cases to be immensely satisfying. You have to love the wire work though because that will be your bread and butter. Cheers.
 
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I think @mimelim is a vascular surgeon, if memory serves.
 
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Hi,

Can somebody comment on the direction vascular surgery is going? I'm hearing that IC and IR is replacing it somewhat? Is there any validity to this? Thank you
 
I love big surgeries just as much as anyone here. It's amazing what some years in a general surgery residency will do to your perspective. As a med student, I'd see a day of gallbladders and hernias and think, "Aw man. Where are the big cases?" Now as a PGY-4, I see a day of gallbladders and hernias and think, "This is going to be a great great day." For whatever crazy reason, I will be applying to vascular surgery this year. The life will be rough, but I find the wide breadth of cases to be immensely satisfying. You have to love the wire work though because that will be your bread and butter. Cheers.

Agree, nice big cases are challenging and fun. But, when you are planning for a strait forward choley or SBO, and it ends up with several hours of "non-planned" challenges on a friday afternoon, the same day as your kids birthday the case is not as fun as when you were med-studen...

Hi,

Can somebody comment on the direction vascular surgery is going? I'm hearing that IC and IR is replacing it somewhat? Is there any validity to this? Thank you

In my opinion it is the way around, IR have lost ground to vasc! at least in Europe. And I'm starting to see my fellow vasc-surgeons less as surgeons and more as IRs. They (the new generation) do call us for basically all laparotomies and bowel resections since they do it less and less...
 
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Vascular is a great field for the right type of person. I like everything about it except maybe toe amps.

There are a few cardiologists doing peripheral work routinely, but this is uncommon. Most cardiologists are busy enough doing heart caths and structural these days. Vascular IR is pretty much dead in places I've ever been at. IR is doing oncology mostly now.
 
Vascular surgery is a great field in huge demand. Sometimes i wonder if I should have done it, but i am not a big fan of open surgery plus i like the breadth of IR.

Vascular IR is alive and well at most places. IR almost everywhere does arterial work these days, however the big brunt of arterial work is tumor embo, uterine fibroid embo, hemorrhage embo. So basically shuttimg vessels off rather than opening. The decline has been in peripheral arterial occlusive disease with the rise of endovascular training for surgeons. But even then, we still do a decent amount nationwide because there are far too many vasculopaths for surgeons to deal with alone and referrals cannbr generated through imaging and having clinic. Also stroke intervention is about to explode and vascular IR is in good position at the moment with it being an add on skill to the other work we do as a lot of the work up is imaging centric.
 
Vascular surgery can't be replaced by another specialty because they own the patient's and most importantly own the PR campaign. I would not let the possible encroachment of other specialties sway your opinion against VS if it's something you're interested in. Furthermore, turf wars are found in nearly every surgical speciality I can think of. Competition makes you better.
 
I would not let the possible encroachment of other specialties sway your opinion against VS if it's something you're interested in.
This is something I'm currently struggling with. For example, say that hypothetically modern carotid stenting is proven to be equal in efficacy to CEA, will cases start to go to Interventional Neuroradiology for CS instead of Vascular Surgery for CEA? At most centers, do Vascular Surgeons handle all carotid work (CS and CEA)?

While it may be a silly way to compare, if you were to bring up a Wikipedia article on both IR and Vascular, it is quite clear that IR has a wider array of therapies throughout the body.

Can someone shed light on whether Vascular Surgeons are starting to expand on their own capabilities? For example, do Vascular Surgeons work on visceral vasculature (ie, mesenteric ischemia)?

I had asked someone the other day whether IR or Vascular Surgeons deal with vascular trauma and was told that it was often IR - shouldn't this be Vascular Surgery territory? Is it center-dependent?

@mimelim I know that you do not think a career in these two fields are comparable, but could you please offer any insight on where you think the future of VS is going?
 
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This is something I'm currently struggling with. For example, say that hypothetically modern carotid stenting is proven to be equal in efficacy to CEA, will cases start to go to Interventional Neuroradiology for CS instead of Vascular Surgery for CEA? At most centers, do Vascular Surgeons handle all carotid work (CS and CEA)

Hard to say about stenting. But i can say that many do do CS. But they do handle all the carotid endarterectomy.

While it may be a silly way to compare, if you were to bring up a Wikipedia article on both IR and Vascular, it is quite clear that IR has a wider array of therapies throughout the body.

Yes that is silly. IR does a lot of stuff all over the body, but vascular surgery can do more in regards to peripheral arterial disease as they do endovascular and SURGICAL treatment. They provide a wide variety of surgical treatment and at this time are at the cutting edge of complex aortic interventions ( although IR also does aortic work at some places ).

Can someone shed light on whether Vascular Surgeons are starting to expand on their own capabilities? For example, do Vascular Surgeons work on visceral vasculature (ie, mesenteric ischemia)?

Yes they have expanded greatly in the past decade and many do mesenteric ischemia with endovascular therapy.

I had asked someone the other day whether IR or Vascular Surgeons deal with vascular trauma and was told that it was often IR - shouldn't this be Vascular Surgery territory? Is it center-dependent?

Vascular surgery does deal with vascular trauma especially surgically. IR tends to do embolizations for traumatic bleeding visceral organs or pelvic fractures.


Long story short, while we do overlap in some procedures, the two fields are very different. I recommend you rotate through both. Keep in mind that IR is very different accross institutions with some places heavy in oncologic work and others heavy in arterial work. If you want to do arterial endovascular and operate, vascular surgery is your best bet.
 
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This is something I'm currently struggling with. For example, say that hypothetically modern carotid stenting is proven to be equal in efficacy to CEA, will cases start to go to Interventional Neuroradiology for CS instead of Vascular Surgery for CEA? At most centers, do Vascular Surgeons handle all carotid work (CS and CEA)?

While it may be a silly way to compare, if you were to bring up a Wikipedia article on both IR and Vascular, it is quite clear that IR has a wider array of therapies throughout the body.

Can someone shed light on whether Vascular Surgeons are starting to expand on their own capabilities? For example, do Vascular Surgeons work on visceral vasculature (ie, mesenteric ischemia)?

I had asked someone the other day whether IR or Vascular Surgeons deal with vascular trauma and was told that it was often IR - shouldn't this be Vascular Surgery territory? Is it center-dependent?

@mimelim I know that you do not think a career in these two fields are comparable, but could you please offer any insight on where you think the future of VS is going?

Ok, so first to deal with your hypothetical - CEA has been shown to have more longevity than CAS, which is why CAS is reserved for those who aren't considered good candidates for CEA. Also vascular surgeons do CAS AND CEA, whereas IR only does CAS. Additionally, many of us think that when the results of CREST2 are released, there will be fewer CEAs and CAS being done in general, as is already the trend in Europe, because medical therapy has improved (statins, dual anti-platelet drugs) and is probably at least equal to outcomes for surgical intervention for asymptomatic carotid disease.

Mesenteric ischemia has always been an area of intervention for vascular surgeons, both with open and now endovascular techniques. Again, IR can do stenting, but you need to remember that vascular surgeons can do both endovascular AND open procedures. Not all patients are candidates for endovascular interventions.

Yes, at my institution, we typically call IR for trauma-sourced endovascular interventions. They also do all the intracranial work. Our vascular guys are busy enough that they aren't worried about IR doing permcaths, ports, trauma, etc. They could coil off a splenic artery if necessary but IR at my institution is probably better at quickly accessing a GDA or what have you. YMMV depending on the institution. FWIW, my vascular attendings are the busiest group in the southeast by volume. Also as far as trauma goes, it is vascular that will deal with an open repair of a radial artery injury, etc.

If all you want to do is wire work, then go for IR. If you enjoy open interventions, vascular access work, AND endovascular, then vascular is a better fit. With an aging population, there's plenty to go around.
 
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Hard to say about stenting. But i can say that many do do CS. But they do handle all the carotid endarterectomy.

Yes that is silly. IR does a lot of stuff all over the body, but vascular surgery can do more in regards to peripheral arterial disease as they do endovascular and SURGICAL treatment. They provide a wide variety of surgical treatment and at this time are at the cutting edge of complex aortic interventions ( although IR also does aortic work at some places ).

Yes they have expanded greatly in the past decade and many do mesenteric ischemia with endovascular therapy.

Vascular surgery does deal with vascular trauma especially surgically. IR tends to do embolizations for traumatic bleeding visceral organs or pelvic fractures.

Long story short, while we do overlap in some procedures, the two fields are very different. I recommend you rotate through both. Keep in mind that IR is very different accross institutions with some places heavy in oncologic work and others heavy in arterial work. If you want to do arterial endovascular and operate, vascular surgery is your best bet.

This was very helpful thank you for your insight!

Ok, so first to deal with your hypothetical - CEA has been shown to have more longevity than CAS, which is why CAS is reserved for those who aren't considered good candidates for CEA. Also vascular surgeons do CAS AND CEA, whereas IR only does CAS. Additionally, many of us think that when the results of CREST2 are released, there will be fewer CEAs and CAS being done in general, as is already the trend in Europe, because medical therapy has improved (statins, dual anti-platelet drugs) and is not probably at least equal to outcomes for surgical intervention for asymptomatic carotid disease.

Mesenteric ischemia has always been an area of intervention for vascular surgeons, both with open and now endovascular techniques. Again, IR can do stenting, but you need to remember that vascular surgeons can do both endovascular AND open procedures. Not all patients are candidates for endovascular interventions.

Yes, at my institution, we typically call IR for trauma-sourced endovascular interventions. They also do all the intracranial work. Our vascular guys are busy enough that they aren't worried about IR doing permcaths, ports, trauma, etc. They could coil off a splenic artery if necessary but IR at my institution is probably better at quickly accessing a GDA or what have you. YMMV depending on the institution. FWIW, my vascular attendings are the busiest group in the southeast by volume. Also as far as trauma goes, it is vascular that will deal with an open repair of a radial artery injury, etc.

If all you want to do is wire work, then go for IR. If you enjoy open interventions, vascular access work, AND endovascular, then vascular is a better fit. With an aging population, there's plenty to go around.
Interesting re: CREST2, I'll have to look into that. So what happens to Vascular Surgeons if they lose CEA/CAS? That's a major procedure, one that made me incredibly interested in the field in the first place.

Out of curiosity, when you say "our vascular guys are busy enough that they aren't worried about IR doing permcaths, ports, trauma, etc," what are they specifically busy with at your institution?

This was also very helpful. Thanks for sharing your perspective!
 
This was very helpful thank you for your insight!


Interesting re: CREST2, I'll have to look into that. So what happens to Vascular Surgeons if they lose CEA/CAS? That's a major procedure, one that made me incredibly interested in the field in the first place.

Out of curiosity, when you say "our vascular guys are busy enough that they aren't worried about IR doing permcaths, ports, trauma, etc," what are they specifically busy with at your institution?

This was also very helpful. Thanks for sharing your perspective!

We'll do what is right for the patient, what is proven by data. CEA is a great procedure and I love it too. So far there's still a benefit shown in symptomatic patients.

Vascular access, access maintenance, emergency and elective lower extremity interventions e.g. endarterectomy, endovascular, and open bypass (Aortobifem, axfem, iliofemoral, fempop, femtib), EVAR/TEVAR/open AAA, mesenteric/renal, elective lower extremity venous work, SVC syndrome/upper extremity venous stenosis, open vascular trauma, exposures for the spine surgeons, also permcaths and ports and IVCFs (plenty to go around, both IR and general surgery do ports and IVCFs too). The odd SC bypass or carotid-carotid bypass as necessary with TEVAR. I'm sure I'm forgetting some things.

Oh, and amputations of course.
 
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IR, VS, Neurosurgery, NIR (and I have no doubt one day Cardiology) all do carotid stents.

No matter which of the above specialities you chose, I can almost garuntee you these things.

1. You'll get a job no problem.

2. You'll be paid very well.

3. You'll wish you had extra specialities around to help you with the volume because you have TOO many cases

Such is the current job market for endovascular specialties.
 
Okay, I guess I will wade in...

#1 Carotids. I have 4 CEAs scheduled this week, next week I have 1 CEA and 1 CAS scheduled. For starters, thank God I did Stroke Neurology as an intern, there is no replacement for being able to do a very good neuro exam and being able to take a very detail oriented stroke/neuro HPI. Devil is in the details and if we had purely gone based on imaging, we would be operating on the wrong side on one of our patients this afternoon. The vast majority of carotid stents in our area are performed by cardiologists. As is most of the peripheral vascular interventions. This is a reflection of the fact that cardiologists control the referral base. After going to a couple of cardiology conferences, this appears to be true across the country, especially outside of major academic centers. There are simply more cardiologists than other endovascular practitioners and they get first crack at the patients since they tend to be in their office for other reasons. Private practice in this country runs very different than academia. The problem is as others have said, if you only have a hammer, everything is a nail. If you don't have the ability to do CEA, you will only offer CAS. That is not good for patients. The reality is that CAS is likely a lot safer than it was in the original trials. But, as safe as CEA? Hard to say if it will get to that point. Complicating this is of course the fact that globally, we really should probably be doing less carotid interventions than we are right now. All of our indications for carotid intervention are based on trials run before statins, plavix, etc. Not exactly "best medical management" currently. This is especially true in the asymptomatic population.

#2 Other specialties doing endo work. I work with a number of extremely technically competent cardiologists and neuro IR guys. However, the number of endo complications that we get from others is staggering. Most of them are access related complications. The number of access vessel injuries at our institution is now 2+/week on average. Then there are the covered stents jailing the profunda, or embolization from shoving catheters/sheaths without wires etc. I am very leary about other specialties doing endo work because their training simply is not as robust. Vascular surgery is 5 years of residency where endo starts on day one. How much interventional training do other specialties do? Anyone can balloon a lesion, anyone can deploy a stent. But, you can really hurt someone without good training. There are nuances that you simply can't get with only 1 or 2 years of training.

#3 Sometimes open surgery is the correct answer. Not every aneurysm should be fixed by EVAR, even if it is technically possible to do it. Again, having the ability to offer both an ABF and an EVAR lets you pick the best option for the patient's specific situation.

#4 The future? probably worth watching in it's entirety for anyone seriously considering vascular surgery, but the point is, even if medications are continuously improving, the pathology is only increasing. We are going to need far more vascular surgeons than we have currently. Our graduates have people chasing after them for practices that need more partners.
 
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We'll do what is right for the patient, what is proven by data. CEA is a great procedure and I love it too. So far there's still a benefit shown in symptomatic patients.

Vascular access, access maintenance, emergency and elective lower extremity interventions e.g. endarterectomy, endovascular, and open bypass (Aortobifem, axfem, iliofemoral, fempop, femtib), EVAR/TEVAR/open AAA, mesenteric/renal, elective lower extremity venous work, SVC syndrome/upper extremity venous stenosis, open vascular trauma, exposures for the spine surgeons, also permcaths and ports and IVCFs (plenty to go around, both IR and general surgery do ports and IVCFs too). The odd SC bypass or carotid-carotid bypass as necessary with TEVAR. I'm sure I'm forgetting some things.

Oh, and amputations of course.

IR, VS, Neurosurgery, NIR (and I have no doubt one day Cardiology) all do carotid stents.

No matter which of the above specialities you chose, I can almost garuntee you these things.

1. You'll get a job no problem.

2. You'll be paid very well.

3. You'll wish you had extra specialities around to help you with the volume because you have TOO many cases

Such is the current job market for endovascular specialties.

Okay, I guess I will wade in...

#1 Carotids. I have 4 CEAs scheduled this week, next week I have 1 CEA and 1 CAS scheduled. For starters, thank God I did Stroke Neurology as an intern, there is no replacement for being able to do a very good neuro exam and being able to take a very detail oriented stroke/neuro HPI. Devil is in the details and if we had purely gone based on imaging, we would be operating on the wrong side on one of our patients this afternoon. The vast majority of carotid stents in our area are performed by cardiologists. As is most of the peripheral vascular interventions. This is a reflection of the fact that cardiologists control the referral base. After going to a couple of cardiology conferences, this appears to be true across the country, especially outside of major academic centers. There are simply more cardiologists than other endovascular practitioners and they get first crack at the patients since they tend to be in their office for other reasons. Private practice in this country runs very different than academia. The problem is as others have said, if you only have a hammer, everything is a nail. If you don't have the ability to do CEA, you will only offer CAS. That is not good for patients. The reality is that CAS is likely a lot safer than it was in the original trials. But, as safe as CEA? Hard to say if it will get to that point. Complicating this is of course the fact that globally, we really should probably be doing less carotid interventions than we are right now. All of our indications for carotid intervention are based on trials run before statins, plavix, etc. Not exactly "best medical management" currently. This is especially true in the asymptomatic population.

#2 Other specialties doing endo work. I work with a number of extremely technically competent cardiologists and neuro IR guys. However, the number of endo complications that we get from others is staggering. Most of them are access related complications. The number of access vessel injuries at our institution is now 2+/week on average. Then there are the covered stents jailing the profunda, or embolization from shoving catheters/sheaths without wires etc. I am very leary about other specialties doing endo work because their training simply is not as robust. Vascular surgery is 5 years of residency where endo starts on day one. How much interventional training do other specialties do? Anyone can balloon a lesion, anyone can deploy a stent. But, you can really hurt someone without good training. There are nuances that you simply can't get with only 1 or 2 years of training.

#3 Sometimes open surgery is the correct answer. Not every aneurysm should be fixed by EVAR, even if it is technically possible to do it. Again, having the ability to offer both an ABF and an EVAR lets you pick the best option for the patient's specific situation.

#4 The future? probably worth watching in it's entirety for anyone seriously considering vascular surgery, but the point is, even if medications are continuously improving, the pathology is only increasing. We are going to need far more vascular surgeons than we have currently. Our graduates have people chasing after them for practices that need more partners.


Thank you all for your willingness to take time out of your busy days to answer my questions.

@LucidSplash that is an awesome list. It seems like there's a lot of breadth in the realm of vascular surgical interventions. @Radz123, thanks for your insight regarding the income for endovascular proceduralists. I had no doubt that they made that they made a substantial amount of money, so that was reaffirming.

@mimelim thank you for offering your insight. Currently it seems that there is a lot of carotid work for vascular surgeons, but you stated that "CAS is likely a lot safer than it was in the original trials. But, as safe as CEA? Hard to say if it will get to that point." - What if it does get to that point? Is it possible that with improved technique in the coming years that carotid stenting (vs. CEA) and other endovascular procedures (ie, bypass vs. angioplasty/atherectomy/stenting for PAD) will be perfected to the degree that open vascular interventions will only become used on an "only if absolutely needed" basis and will fall out of favor in treatment algorithms?

I just watched the 2016 Presidential Address and found it incredibly inspiring. It is exciting to hear someone speak with such intense compassion regarding the care of their patients. However, while the future was discussed in terms of demand (ie, "we need more vascular surgeons to handle the aging population"), not much was discussed in terms of operative advances, development of novel techniques, and new technology to treat this growing elderly population. For example, I've heard that there is a percutaneous approach for AV fistula formation being developed. This sounds like something that other interventional proceduralists might be able to perform if adequately trained. Are there techniques being developed by Vacular Surgeons that, in the future, will be exclusive to their field? I know you guys can't see into the future, but based on your "best guess" (and outside of strictly emergency situations), do you see open vascular interventions thriving over the next 20 years? If not, is there leadership in Vascular Surgery pushing for its field to have total control over the domain of particular endovascular interventions?

Thank you all for your insight. This has been very helpful.
 
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Thank you all for your willingness to take time out of your busy days to answer my questions.

@LucidSplash that is an awesome list. It seems like there's a lot of breadth in the realm of vascular surgical interventions. @Radz123, thanks for your insight regarding the income for endovascular proceduralists. I had no doubt that they made that they made a substantial amount of money, so that was reaffirming.

@mimelim thank you for offering your insight. Currently it seems that there is a lot of carotid work for vascular surgeons, but you stated that "CAS is likely a lot safer than it was in the original trials. But, as safe as CEA? Hard to say if it will get to that point." - What if it does get to that point? Is it possible that with improved technique in the coming years that carotid stenting (vs. CEA) and other endovascular procedures (ie, bypass vs. angioplasty/atherectomy/stenting for PAD) will be perfected to the degree that open vascular interventions will only become used on an "only if absolutely needed" basis and will fall out of favor in treatment algorithms?

I just watched the 2016 Presidential Address and found it incredibly inspiring. It is exciting to hear someone speak with such intense compassion regarding the care of their patients. However, while the future was discussed in terms of demand (ie, "we need more vascular surgeons to handle the aging population"), not much was discussed in terms of operative advances, development of novel techniques, and new technology to treat this growing elderly population. For example, I've heard that there is a percutaneous approach for AV fistula formation being developed. This sounds like something that other interventional proceduralists might be able to perform if adequately trained. Are there techniques being developed by Vacular Surgeons that, in the future, will be exclusive to their field? I know you guys can't see into the future, but based on your "best guess" (and outside of strictly emergency situations), do you see open vascular interventions thriving over the next 20 years? If not, is there leadership in Vascular Surgery pushing for its field to have total control over the domain of particular endovascular interventions?

Thank you all for your insight. This has been very helpful.

Endo technology is improving every day. But, the reality is that it is very far behind open operations in terms of durable results. Could it one day surpass open surgery in efficacy? Sure. A pill could also be invented that cures lung cancer making surgery unnecessary. For some patients and anatomies, endo is definitely the correct answer. But, it is hard to imagine open cases disappearing. Atherectomy, DCBs, DCSs etc are all great, but largely unproven, hence why there are so many options out there. As of right now, endo procedures work great, but tend to fail relatively quickly and there are no quick fixes on the horizon. Keep in mind that most vascular surgeon's practices are 70%+ endo, so it isn't like their businesses are being hurt. My best guess is in the next 20 years it will continue to rise, but will slow down rapidly. There will become a steady state similar to coronary interventions.

Regarding the perc AV fistulas, requires very specific anatomy, the vast majority of patients wouldn't qualify. Further, if there is one thing true in AV access, they fail and you always need to be thinking about plans b, c and d. Virtually guaranteed that those options won't be perc. Also, endo tends to require more re-interventions. In the AV world, PTA only lasts ~3 months, then virtually everyone starts to develop restenosis. You can have your patients come in constantly for 3 month touch ups (see the interventional nephrology crowd), but that just seems like a way for doctors to make money rather than a way to help people.
 
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Endo technology is improving every day. But, the reality is that it is very far behind open operations in terms of durable results. Could it one day surpass open surgery in efficacy? Sure. A pill could also be invented that cures lung cancer making surgery unnecessary. For some patients and anatomies, endo is definitely the correct answer. But, it is hard to imagine open cases disappearing. Atherectomy, DCBs, DCSs etc are all great, but largely unproven, hence why there are so many options out there. As of right now, endo procedures work great, but tend to fail relatively quickly and there are no quick fixes on the horizon. Keep in mind that most vascular surgeon's practices are 70%+ endo, so it isn't like their businesses are being hurt. My best guess is in the next 20 years it will continue to rise, but will slow down rapidly. There will become a steady state similar to coronary interventions.

Regarding the perc AV fistulas, requires very specific anatomy, the vast majority of patients wouldn't qualify. Further, if there is one thing true in AV access, they fail and you always need to be thinking about plans b, c and d. Virtually guaranteed that those options won't be perc. Also, endo tends to require more re-interventions. In the AV world, PTA only lasts ~3 months, then virtually everyone starts to develop restenosis. You can have your patients come in constantly for 3 month touch ups (see the interventional nephrology crowd), but that just seems like a way for doctors to make money rather than a way to help people.
This clears a lot up for me. @mimelim, and others like @LucidSplash, would you guys mind offering why you chose Vascular Surgery? Were you were considering any other fields? What was it that helped you make your final decision? Where do you hope to see Vascular Surgery, as a field, in 10 years?

Thank you all for answering my questions, you have been very helpful.
 
Since you guys are getting inundated with questions, I have one: do you know of anyone who underwent both a vascular surgery as well as a CT surgery training? It sounds really appealing to me but I don't know if it's realistic.
 
Since you guys are getting inundated with questions, I have one: do you know of anyone who underwent both a vascular surgery as well as a CT surgery training? It sounds really appealing to me but I don't know if it's realistic.

I know several that did that. Also not unheard of to do both in practice.
 
I know several that did that. Also not unheard of to do both in practice.

What was the pathway that they pursued in order to receive training in both? Integrated Vascular then CT fellowship? Integrated CT then Vascular fellowship?
 
What was the pathway that they pursued in order to receive training in both? Integrated Vascular then CT fellowship? Integrated CT then Vascular fellowship?

These were all residents back before any integrated pathways, so general surgery and then some did both CT and vascular fellowships. I know some that have done just CT fellowships and do some vascular in their practice.
 
These were all residents back before any integrated pathways, so general surgery and then some did both CT and vascular fellowships. I know some that have done just CT fellowships and do some vascular in their practice.
That's awesome. Do you think it's possible to do this from one of the integrated pathways?
 
Vascular's pretty great.

I grew to enjoy the cases that I thought would be boring as a medical student, i.e. anything endovascular. It's pretty painful to just sit there and watch an endo case as a student, and it's not that much better when as the intern you're just standing at the end managing the end of the lunderquist. However, once you start doing the cases, even all the leg angios can be kinda fun.

Okay, I guess I will wade in...

#1 Carotids. I have 4 CEAs scheduled this week, next week I have 1 CEA and 1 CAS scheduled. For starters, thank God I did Stroke Neurology as an intern, there is no replacement for being able to do a very good neuro exam and being able to take a very detail oriented stroke/neuro HPI. Devil is in the details and if we had purely gone based on imaging, we would be operating on the wrong side on one of our patients this afternoon. The vast majority of carotid stents in our area are performed by cardiologists. As is most of the peripheral vascular interventions. This is a reflection of the fact that cardiologists control the referral base. After going to a couple of cardiology conferences, this appears to be true across the country, especially outside of major academic centers. There are simply more cardiologists than other endovascular practitioners and they get first crack at the patients since they tend to be in their office for other reasons. Private practice in this country runs very different than academia. The problem is as others have said, if you only have a hammer, everything is a nail. If you don't have the ability to do CEA, you will only offer CAS. That is not good for patients. The reality is that CAS is likely a lot safer than it was in the original trials. But, as safe as CEA? Hard to say if it will get to that point. Complicating this is of course the fact that globally, we really should probably be doing less carotid interventions than we are right now. All of our indications for carotid intervention are based on trials run before statins, plavix, etc. Not exactly "best medical management" currently. This is especially true in the asymptomatic population.

#2 Other specialties doing endo work. I work with a number of extremely technically competent cardiologists and neuro IR guys. However, the number of endo complications that we get from others is staggering. Most of them are access related complications. The number of access vessel injuries at our institution is now 2+/week on average. Then there are the covered stents jailing the profunda, or embolization from shoving catheters/sheaths without wires etc. I am very leary about other specialties doing endo work because their training simply is not as robust. Vascular surgery is 5 years of residency where endo starts on day one. How much interventional training do other specialties do? Anyone can balloon a lesion, anyone can deploy a stent. But, you can really hurt someone without good training. There are nuances that you simply can't get with only 1 or 2 years of training.

#3 Sometimes open surgery is the correct answer. Not every aneurysm should be fixed by EVAR, even if it is technically possible to do it. Again, having the ability to offer both an ABF and an EVAR lets you pick the best option for the patient's specific situation.

#4 The future? probably worth watching in it's entirety for anyone seriously considering vascular surgery, but the point is, even if medications are continuously improving, the pathology is only increasing. We are going to need far more vascular surgeons than we have currently. Our graduates have people chasing after them for practices that need more partners.


Agree. Going along with what you're saying...

Re: optimal medical therapy... we've seen this with coronary stents. Between FAME and COURAGE, coronary interventions have taken a hit.

Re: other specialties, IR and IC will often just fix something radiographically (beautiful completion angio), but vascular surgery is equipped to actually take care of the real problem: claudication, non-healing wound, etc.

These were all residents back before any integrated pathways, so general surgery and then some did both CT and vascular fellowships. I know some that have done just CT fellowships and do some vascular in their practice.

I believe that vascular fellowships do allow training following integrated ct training. I'm not sure that you'd be able to do a ct fellowship after vascular integrated.

CT after integrated vascular is ok:
https://abts.org/root/home/certification/general-requirements.aspx

I also know a couple of guys who did general surgery then CT fellowship and will do some open vascular stuff on the side. Not so much the endovascular stuff, though. It seems like this will become less common as more people push for the endovascular option.
 
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This clears a lot up for me. @mimelim, and others like @LucidSplash, would you guys mind offering why you chose Vascular Surgery? Were you were considering any other fields? What was it that helped you make your final decision? Where do you hope to see Vascular Surgery, as a field, in 10 years?

Thank you all for answering my questions, you have been very helpful.

Sorry for late response. Long week.

I like vascular for the variety of cases (noted above). I like being able to go between open and minimally invasive work, the variety of technology (seemingly ever expanding). The technical aspects of sewing vessels appeals to me as well. (I feel like I should just copy and paste my application personal statement LOL).

Also, I hate hate hate sacral decubs and enterocutaneous fistulas. HATE. Somehow I find these disease processes more depressing than vascular disease. I can handle of leg that needs a guillotine amp - that's like 15 secconds and it is gone. Sacral decubs and ECF are the gifts that keep on giving. I really like vascular work AND it gets me away from the two things I dislike the most. WIN.
 
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Sorry for late response. Long week.

I like vascular for the variety of cases (noted above). I like being able to go between open and minimally invasive work, the variety of technology (seemingly ever expanding). The technical aspects of sewing vessels appeals to me as well. (I feel like I should just copy and paste my application personal statement LOL).

Also, I hate hate hate sacral decubs and enterocutaneous fistulas. HATE. Somehow I find these disease processes more depressing than vascular disease. I can handle of leg that needs a guillotine amp - that's like 15 secconds and it is gone. Sacral decubs and ECF are the gifts that keep on giving. I really like vascular work AND it gets me away from the two things I dislike the most. WIN.
Thank you for the response. I feel the same way about everything you said.

At your institution, do you often have to deal with debridement of gangrenous feet? Or is there a podiatry division that is primarily responsible for these, so that you and your team are able to specifically focus on the underlying vascular disease?
 
Thank you for the response. I feel the same way about everything you said.

At your institution, do you often have to deal with debridement of gangrenous feet? Or is there a podiatry division that is primarily responsible for these, so that you and your team are able to specifically focus on the underlying vascular disease?

We do feet. There is podiatry and sometimes we will consult them after we do an initial debridement in conjunction with arteriogram. But we do rays, TMAs, etc. If the patient doesn't have actual vascular disease by duplex or has palpable pulses, sometimes they'll hand off to podiatry from the outset. It varies by attending.
 
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We do feet. There is podiatry and sometimes we will consult them after we do an initial debridement in conjunction with arteriogram. But we do rays, TMAs, etc. If the patient doesn't have actual vascular disease by duplex or has palpable pulses, sometimes they'll hand off to podiatry from the outset. It varies by attending.
Interesting, thanks for the info.

Are you and others who you have spoken to, anecdotally, happy as Vascular Surgeons?
 
I know several that did that. Also not unheard of to do both in practice.

By mistake, pressed the wrong reply button. :) By the way, always enjoy reading your posts. Thank you.
 
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Since you guys are getting inundated with questions, I have one: do you know of anyone who underwent both a vascular surgery as well as a CT surgery training? It sounds really appealing to me but I don't know if it's realistic.

Allegheny General Hospital offered at some point, maybe still do, VS-CT training. I believe it is within their VS I6 program, but you'll have to check with the AGH's VS Department.
 
Allegheny General Hospital offered at some point, maybe still do, VS-CT training. I believe it is within their VS I6 program, but you'll have to check with the AGH's VS Department.

They do. I was more curious if it was realistic in practice-- as in, do people end up doing both.
 
They do. I was more curious if it was realistic in practice-- as in, do people end up doing both.

It happens more often in smaller hospitals. Maybe there's not enough CT volume for the surgeon, so they make up for it was Vascular volume. You'll probably be less likely to find it in a large metro area.
 
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From what I understand from fellowship interviews, there will be no shortage of vascular work. We have the ability to do endo and open cases. IR is actually a helpful adjunct in some cases to offload some diagnostic angios and other fairly basic things that may otherwise overload some practices.

Currently, I am a resident at a facility that has IR and CT and no vascular surgeons. It is horrible. CT guys take all the vascular consults, but as someone said above if you have a hammer everything looks like a nail. They do not do any endo and if they can't do an open bypass, they recommend gen surg do an amp. The way they do things is also substandard, i.e. don't patch carotids on CEA, don't harvest contralateral vein for traumatic injury repairs, don't do fasciotomy for ischemic time >4 hours etc. Maybe it's different elsewhere but I think CT should confine themselves to the chest where they know what they are doing. Peripheral vascular and CT are very different specialties with minimal crossover.
 
From what I understand from fellowship interviews, there will be no shortage of vascular work. We have the ability to do endo and open cases. IR is actually a helpful adjunct in some cases to offload some diagnostic angios and other fairly basic things that may otherwise overload some practices.

Currently, I am a resident at a facility that has IR and CT and no vascular surgeons. It is horrible. CT guys take all the vascular consults, but as someone said above if you have a hammer everything looks like a nail. They do not do any endo and if they can't do an open bypass, they recommend gen surg do an amp. The way they do things is also substandard, i.e. don't patch carotids on CEA, don't harvest contralateral vein for traumatic injury repairs, don't do fasciotomy for ischemic time >4 hours etc. Maybe it's different elsewhere but I think CT should confine themselves to the chest where they know what they are doing. Peripheral vascular and CT are very different specialties with minimal crossover.

Just fyi, Makaroun doesn't patch CEAs either. I'm told that because of that, neither does any of the surgeons at Pitt. Also, there are several prominent neurosurgery groups that don't patch routinely either. Not saying that it is right and we certainly (15+ surgeons in the group) patch every CEA, but even within vascular surgery there is some that are pretty anti-patching.
 
The idea of fasciotomy was also controversial among some vascular surgeons as well.
 
The idea of fasciotomy was also controversial among some vascular surgeons as well.
Well, I have seen multiple legs die after GSW to SFA in young trauma patients, for example, that they bypassed. This is after prolonged ischemic time because they insist on getting a CTA, then IR in to do an angio before even considering the OR. Post op, the patient goes to ICU, gets resuscitated and then gets compartment syndrome. We call and tell them about change in status and they say "nothing to do." We then end up amputating.
 
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Do your trauma surgeons not fasciotomize?

Usually for traumatic revascularizations our vascular guys will prophylactically fasciotomize themselves, but our trauma attendings do their fair share too.

There are some that will, but I have only done like one fasciotomy with a trauma attending. I don't know if it has to do with the fact that CT acting as vascular "owns" leg or what.

I really hate scrubbing with that group but will often go just to make sure my feelings about fasciotomy are known. Usually they say no, but if they leave me to close, I have been know to grab some scissors and do the fasciotomy surreptitiously. In one case with a brachial artery injury and like 5 hours ischemia, we had fairly large incisions and I just slid the mayos down the fascia to the hand while the attending was dictating. The arm lived.
 
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What are your thoughts on non-traumatic fasciotomy for acute ischemic limb?

We do them quite frequently. My attendings are pretty on top of stuff like this and expect us to be as well. We then wrap it up really well because it's going to ooze and the nurses are going to call. Then in a few days we start to close it at the bedside.
 
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