Vascular Fellowships

[Dr. Bob]

Does anyone have any well grounded opinions on the top vascular fellowships? A few that stand out seem to be Stanford and UNC given their strong endovascular training.

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[njbmd]

Does anyone have any well grounded opinions on the top vascular fellowships? A few that stand out seem to be Stanford and UNC given their strong endovascular training.

Hi there,
I am kind of partial to Cleveland Clinic and University of Virginia for obvious reasons. UVA is still a one-year program with good endovascular experiences.
njbmd

 

[Dr. Bob]

Don't know much about the Cleveland Clinic or UVa.

It just seems that a lot of the programs that were considered really exceptional are rather dated in their training.

It seems that it is difficult for some of these Vasc programs to evolve in the setting of a strong CT surgery department/rads department/cards department.

Some programs haven't even started thoracic endografts and others lost turf battles to the interventionalists (see UTSW).

The irony is that you really need the interventionalists to assist in the development of new endovascular techniques and to teach these skills to the fellows. I think it's counterproductive to exclude them in this field (see UWash).

Also, I seriously question the ability to adequately train a Vasc fellow to be able to practice in this field with only one year of clinical training. These programs will start to require another year soon. There has even been talk about going to a plastics model with a 3 and 3 format.

Of course in the end thoracic endografts and carotid stents will be put in by Cardiologists while no vascular surgeons will know how to perform an open AAA.

 

[vent]

Albert Enstien's College of Medicine headed by Frank Veith is really very powerful, especially in endovascular AAA. University of Arizona is also seems to be good. Cleveland Clinic Foundation like any other field seems glamorous. Mayo clinic, Jacksonville well established international reputation.

 

[RADRULES]

The IR guys are finally getting into the game are becoming more and more clinically oriented. This could spell doom for the VS guys who want to steal this area which was pioneered and developed by IR. It would be wise, in my estimation, for VS and IR to work together in this area. I seriously doubt that the interest in either party is going to be served by Cardiology taking over the vast majority of endovascular work. It is my opinion that VS and IR could have a great relationship in the future if cards are kept out of the equation.

A symbiotic relationship between VS and IR is best for medicine and the patients. Cards guys are sloppy and greedy.

 

[droliver]

The IR guys are finally getting into the game are becoming more and more clinically oriented. This could spell doom for the VS guys who want to steal this area which was pioneered and developed by IR.

That's kind of wishful thinking I believe in most scenarios. IR is going to come up on the short end of the stick whenever Cardiologists & Vascular Surgeons play hardball on this one. Both of the competing specialties usually have access to the patients first as well as either onsite complication management (in the case of vascular surgery) or CTVS surgeons being strongarmed into backing up the Cardiologists that may not be available to radiologists. If you don't have that, you can't do these larger vascular procedures.

I'm not even sure there will be that much interest by most radiologists in dabbling in this area. It's fairly high risk/low reward financially compared to other areas of radiology & brings a whole lot of lifestyle "modifiers" that many people went into Radiology to avoid in the first place. There're some open threads on the radiology board currently about the large number of residents avoiding IR for this reason & noting that most of the fellowships are not filling.

 

[njbmd]

Of course in the end thoracic endografts and carotid stents will be put in by Cardiologists while no vascular surgeons will know how to perform an open AAA.

Hi there,

Not every AAA is amenable to repair by endograft. Most AAAs so far are not so there is still plenty of work for vascular and general surgeons. I'm not worried about finding a job or encroachment by IR.

njbmd

 

[Dr. Bob]

vent-good point about Einstein. As a grad of U of A I can guarantee that they will find a way to make that department underachieve which is unfortunate since AZ is great state to live in.

RADRULES-very good points. But don?t underestimate the cards guys. They have enough lack of ethics to stent Pts with one vessel dz knowing that they would achieve better patentcy with a relatively low risk CABG. Recent studies support what is a relatively easy deployment of carotid stents on their part. Med will prob refer to cards and cards will be doing all the carotids soon.

droliver-good point. I think IR could do a very good job in this field but god forbid that they have to start running a clinic to follow their patients. This is the one advantage Vasc surg has.

njbmb-of course not all AAAs can undergo endo repair but the majority do. The bread and butter is being lost just like the straightforward CABG was lost from CT surg. I tend to think it would behoove the Vasc guys to just learn to stent their Pt's TAA, AAA, iliacs ect until they eventually die from a MI as the bypass studies have shown us.

Any opinions on the UCSF, UWASH, WASHU, MICHIGAN, BAYLOR programs?

 

[njbmd]

njbmb-of course not all AAAs can undergo endo repair but the majority do. The bread and butter is being lost just like the straightforward CABG was lost from CT surg. I tend to think it would behoove the Vasc guys to just learn to stent their Pt's TAA, AAA, iliacs ect until they eventually die from a MI as the bypass studies have shown us.

Any opinions on the UCSF, UWASH, WASHU, MICHIGAN, BAYLOR programs?

Hi there,
Here at UVA, we do far less stents than open procedures as again, the lesions just are not amenable to stents. We try to stent the folks who are candidates but few are. We have an excellent IR department with whom we work very closely but stents are not the answer or the norm.

AAAs are far from being the "bread and butter" of vascular surgeons but rather we do far more carotids than aneurysms. TAAs are done by the CT surgeons and will continue to be done by CT. If an aneurysm extends into the abdominal cavity, we share the repair. Again, if the lesion can be stented here, it is.

There are many procedures that the IR folks call us to be standing by especially the stents and angios of SMA etc. They still cannot take care of their problems and perforations. When the stents close (gee whiz) it is the vascular surgeon that does the definitive repair. I do not believe for one second, that vascular surgery is an endangered field from IR. We work together on most of the cases. Someone has to open the groins and close for IR for stents. Many hospitals do not grant admitting privileges to radiologists and medicine runs away from anything vascular.

We had an interventional resident rotate through vascular to attempt to obtain the training to do the groins but still, this is left to the vascular surgeons. They quickly bagged the idea when the complication rate went up and they still had to call the vascular surgeons.

Cheers,
njbmd

 

[RADRULES]

My point never really that IR will put VS out of business. Naaa... that is not going to happen, mainly because IR is branching out into many different new and exciting areas (interventional oncology, orthopedic intervention, MR based intervention) which is really where most IR guys want to be. Of course, the vascular work is there and is cool, but frankly I see a time fairly soon where CTA and MRA will replace conventional angio. The real threat is Cards stealing the stenting from the VS and IR guys, and that is what I feel the two fields should work together to prevent. Like I said, at most places VS and IR guys work closely and bail each other out - not an adversarial relationship.

Most IR people are moving into a clinical direction, with clinics and admitting patients. Also, lots of IR folks are getting referrals directly from primary care people these days, to whom they advertise their services.

In any case, IR is a extremely innovative specialty and I doubt that anyone in IR is interested in stealing lunch money from VS. Cards, on the other hand, are a threat to everyone (including patients!). Later.

 

[aboo-ali-sina]

I want to throw Albany Medical Center in Albany NY into the running. Home to some of the pioneers in vascular surgery like Dr. Karmody and Dr. Leather; as well as some high power contemporaries like Dr. Shah, Dr. Darling, and Dr. Chang, AMC is argueably the largest vascular center on the East Coast. Additionally, with the recruitment of one of Frank Veith's protege's (Dr. Mehta) AMC is strong in endovascular surgery. The IR and VS have formed a union (both finanically and fiduciarily) to bring AMC to the forefront of endografts. The vascular fellows do AAA and Thoracic grafts all the time. Additionally, they spend 6 mo with the IR guys doing diagnositic procedures as well as Renal artery stents, and distal artery stents. As for open procedures: CEA's (using the inversion technique pioneered by Dr. Leather and Dr. Shah), distal bypasses (both insitu (as Pioneered by Dr. Leather) and invertion), major aortic procedures (through a retroperitoneal approach (as pioneered by Dr. Darling and Dr. Shah)), as well as loads of other procedures for arterial and venous insufficiency are done routinely by the fellow.

The system here is amazing for training, the fellow is busy and will work hard. He spends the first 6 mo in the lab M-Th and operating/oncall every other Fri-Sun. Then the next 3 mo are spent on IR. Then 3 mo straight VS (like 6-10 cases a day). Then 3 more months IR. Followed by the last 9 mo VS (doing open and endovascular cases).

I can not over emphasize the volume of cases that come through AMC. The vascular service typically has 60-100 patients in house at any given time (this is in a 647 bed hospital).

AMC is the level 1 trauma center for East Upstate NY, Vermont, New Hampshire, and west mass. All aorta's get flown here. About 30 ruptured AAA come here a year.

The Vascular Group at AMC is high productive in research. The fellows get to ride on those coat tails. They present at every major meeting.

It is a 2 year program. One fellow a year. It could probably support another 2 fellows every year.

As you can tell, I am pretty positive about this fellowship. PM if you have any questions.

 

[runnermoore]

AMC is the level 1 trauma center for East Upstate NY, Vermont, New Hampshire, and west mass. All aorta's get flown here. About 30 ruptured AAA come here a year.

Not that it has much bearing on the theme of this thread, but: your claim about AMC being the level 1 for such a large catchment area is flawed. Dartmouth covers most of northern and central NH, UVM gets most of VT and northern NY, while Boston gets lots of stuff from southern NH.

 

[aboo-ali-sina]

That is true, i was not specific in my catchman description because I didn't think it was super relevant. but it's catchman does incloud southern vt, south western NH and north western MA North east NY up to platskill, as far west as oneonta and as far south as westchester NY

Hope that clears up any confusion