Vascular Surgery v/s Interventional Radiology
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This actually makes for an interesting topic of conversation.
In the endovascular arena (stenting, stentgrafts, etc...) I think the vascular guys will have the upper hand. Then again, there are procedures that the IR guys do and will continue to do (embolisations, hepatic work, biopsies, etc...)
It may be a wash for a while and it may depend on region and/or hospital. There are now combo vascular surgery/interventional radiology fellowships coming into the playing field too. An interesting topic to watch indeed.
In the endovascular arena (stenting, stentgrafts, etc...) I think the vascular guys will have the upper hand. Then again, there are procedures that the IR guys do and will continue to do (embolisations, hepatic work, biopsies, etc...)
It may be a wash for a while and it may depend on region and/or hospital. There are now combo vascular surgery/interventional radiology fellowships coming into the playing field too. An interesting topic to watch indeed.
Vascular Surgeons & Cardiologists will win this one hands down for the procedures they wish to exert themselves in. They own the referrals, and in the case of the vascular surgeons they own the ultimate trump card of refusing to provide backup for a radiologist. Cardiology can leverage their relationship with the CV surgeons to expose the femoral vessels for endo-stents and to ensure they have back up.
Having done a number of these in a former life and seen a number of complications requiring urgent surgical intervention, I feel strongly that most of these (particularly the AAA endostents) should be done in an OR angio suite. It's the only thing that makes sense from a patient safety perspective.
Having done a number of these in a former life and seen a number of complications requiring urgent surgical intervention, I feel strongly that most of these (particularly the AAA endostents) should be done in an OR angio suite. It's the only thing that makes sense from a patient safety perspective.
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Interesting points.
Would love to read more opinions/views.
Would love to read more opinions/views.
Of course by this logic, cardiologists shouldn't be doing caths, gastroenterologists shouldn't be doing scopes, nobody but surgeons should be doing paracentesis (there is a small risk of bowel perf), and OB/GYNs shouldn't operate at all.
That being said, the patient control issue has definitely given vascular surgeons and cardiologists the upper hand in this and they will likely continue to push radiologists out. Luckily IRs are innovative and are plenty busy without the arterial work.
Of course, a good interventional radiologist can be a surgeons best friend, but the strong arm tactics of the vascular surgeons is causing a rift between these two specialties.
IR is slowly disappearing from the arterial intervention landscape. They typically have no admitting privileges, no ability to manage inpatients, and no control over the referals. The only reason some IR interventional programs remain busy is because they control credentialling and equipment and can administratively box out vascular surgery. There are also a fair number of old-time vascular surgeons who don't have catheter skills and preserve the old vascular surgery/IR referal pattern.
But as young vascular surgeons come out of training with huge numbers of interventional cases (more arterial cases than many IR fellows), and most new vascular surgeons do all their own interventional work, it is becoming increasingly difficult for IR to compete.
Of course the big elephant in the room is cardiology, which controls a huge patient base, has control over the angio suite, knows how to take care of inpatients, and clearly has all of the required catheter skills.
In the future, I'm guessing the situation will for various procedures will shake out as follows.
Renal angioplasty: Totally cardiology domination since they conrol so many of the hypertensives. Referal of failures to vascular surgery
Simple SFA and iliac intervention: Dominated largely by cardiology with some vascular surgery
Complex limb salvage/long segment iliac-sfa occlusions: Vascular surgery domination since the need for adjuctive surgical procedures and complications are frequent.
AAA endograft: Vascular surgery domination since most procedures still done with femoral cut-down, complications cannot be easily managed by cardiolgy, and reimbusement is not that great given time requirements for planning and follow-up.
Carotid stent: Mix of vascular surgery and cardiology. Recent trends away from stenting and lack of CMS reimbursment for most cases has kept cardiology at bay.
AVM/chemoembolization: IR dominates since these are such rare, tertiary referal cases
Aortic arch endograft/percutaneous valve: CT surgery. No way to do these cases without CT involvement
Five years ago, my vascular surgical colleagues were all bitching and moaning about IR denying them credentials for angioplasty. These days no one gives a crap about IR and we are all worried about cardiology scooping up the easy, high-reimbursment cases.
My thoughts as a vascular surgeon.
But as young vascular surgeons come out of training with huge numbers of interventional cases (more arterial cases than many IR fellows), and most new vascular surgeons do all their own interventional work, it is becoming increasingly difficult for IR to compete.
Of course the big elephant in the room is cardiology, which controls a huge patient base, has control over the angio suite, knows how to take care of inpatients, and clearly has all of the required catheter skills.
In the future, I'm guessing the situation will for various procedures will shake out as follows.
Renal angioplasty: Totally cardiology domination since they conrol so many of the hypertensives. Referal of failures to vascular surgery
Simple SFA and iliac intervention: Dominated largely by cardiology with some vascular surgery
Complex limb salvage/long segment iliac-sfa occlusions: Vascular surgery domination since the need for adjuctive surgical procedures and complications are frequent.
AAA endograft: Vascular surgery domination since most procedures still done with femoral cut-down, complications cannot be easily managed by cardiolgy, and reimbusement is not that great given time requirements for planning and follow-up.
Carotid stent: Mix of vascular surgery and cardiology. Recent trends away from stenting and lack of CMS reimbursment for most cases has kept cardiology at bay.
AVM/chemoembolization: IR dominates since these are such rare, tertiary referal cases
Aortic arch endograft/percutaneous valve: CT surgery. No way to do these cases without CT involvement
Five years ago, my vascular surgical colleagues were all bitching and moaning about IR denying them credentials for angioplasty. These days no one gives a crap about IR and we are all worried about cardiology scooping up the easy, high-reimbursment cases.
My thoughts as a vascular surgeon.
Ahh... That logic, though practical, hasn't stopped anyone from doing what they damn well please with patients. The belief, of course, is those who play a game with which they are entirely unfamiliar will be able to find someone who's willing to bail them out.
Think a cardiologist can't do an aorotic endograft because they can't perform the femoral cutdown? I've known CT surgeons, who are at the mercy of cardiologists, to perform the cutdown for them. I'm sure the same CT surgeon will be more than happy to lap the patient to fix the AAA if something were to go awry with the EVAR.
The same scenario is played out in fields other than Vascular Surgery. Optometrists vs. Ophthalmologists, General Surgery vs. Gastroenterology (Endoscopy/NOTES), Anesthesiology vs. CRNAs (?), Primary Care Medicine vs. NPs. I'm sure if the liability weren't so damn high, Midwives would be battling Obstetrics for everything too including the right to cut!
Anyone know how the Optometrists' are doing with wanting to perform LASIK and other related procedures?
My responses to most of the above posts
1. vascular surgery and radiology work together, they both need and learn off of each other. Radiologists wont go hungry if vascular surgeons do stenting, IR also do hepatobiliary, GI, and urological work too. And vascular surgeons have OTHER things to do then stenting people they dont just sit around twiddling their thumbs.
2. People seem to think that cardiologists can do everything . Those who do are underestimating how complex cardiac catheterization is. If you dont do similar procedures over and over again you get de-skilled! This is a point I have stressed over and over in the cardiology vs CT threads. You cant expect interventional cardiologists to do the work of an interventional vascular radiologist on top of their own cardiology commitment this isnt realistic and probably isnt safe.
3. Interventions on the thoracic aorta will ALWAYS require CT (and sometimes vascular) input because of the complexity of this field. No two thoracic aneurysms are the same so a team approach is needed.
4. CT would never do a lap to fix an infra-renal AAA endo-leak. (I dont care if someone knows a guy who did it) for the vast majority of CT surgeons its not their domain.
Just my two cents
1. vascular surgery and radiology work together, they both need and learn off of each other. Radiologists wont go hungry if vascular surgeons do stenting, IR also do hepatobiliary, GI, and urological work too. And vascular surgeons have OTHER things to do then stenting people they dont just sit around twiddling their thumbs.
2. People seem to think that cardiologists can do everything . Those who do are underestimating how complex cardiac catheterization is. If you dont do similar procedures over and over again you get de-skilled! This is a point I have stressed over and over in the cardiology vs CT threads. You cant expect interventional cardiologists to do the work of an interventional vascular radiologist on top of their own cardiology commitment this isnt realistic and probably isnt safe.
3. Interventions on the thoracic aorta will ALWAYS require CT (and sometimes vascular) input because of the complexity of this field. No two thoracic aneurysms are the same so a team approach is needed.
4. CT would never do a lap to fix an infra-renal AAA endo-leak. (I dont care if someone knows a guy who did it) for the vast majority of CT surgeons its not their domain.
Just my two cents
never had an issue with IR and vascular surg. they help us out all the time. it's medicine residents with additional cardiology training, stealing vascular surgery procedures (that are non-cardiac) that ruffles my feathers.
how do they get privileges, anybody know?
Time to check our egos at the door. Lets be honest we help each other out --no body is perfect. From the IR stand point we seldom need call for backup unless something goes horribly wrong. We usually clean up after ourselves just fine.
I remember vascular saved us once after a after a tough femoral stick for an intraop 4 vessel angiogram. It was a neurosurg patient who was scrubbed in in sitting position and NS would not let us put him supine. We had to put the sheath in a fat guy in 'sitting' position. Ever try that? next to impossible, took us a while then we finally got access. The foot got cold afterwards, turns out the intima was shredded. VS did a vein graft and saved his leg. It would have sucked for him to lose his foot.
The flip side, there are times when we really helped out VS when they broke a plaque loose doing carotid stenting and subclavian angioplasty causing MCA/PCA artery emboli, respectively in 2 separate patients, and we did emergent thrombectomy/thrombolysis. It would have REALLY sucked to if that patient ended up hemiplegic or died.
I agree with the last post, when it comes to peripheral vessels vascular surgery brings a valuable skill set to the table. IR does too. Exactly what does cards bring to the table?
Hmm... still thinking.....
Patients. More of them than Vascular Surgery could ever bring.
Uh...how...about...these:
A massive referal base of patients with PVD
A giant money-making machine for the hospital
Adequate catheter skills
Extensive participation in clinical trials
Comprehensive knowledge of risk factor/lipid management
Willingness to manage inpatients and their complications
Hey, I don't like cardiology either, but you have to be realistic. From the hospital perspective, they bring a lot.
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Cards brings in money as does neurosurgery and ortho and even rads...
I'm being a little facetious... 🙄 come on people...
Interesting arguments.
Never knew about all this fuss going on in the field of medicine
Never knew about all this fuss going on in the field of medicine
I'm not sure I buy your idea that one person can't have both those skillsets - I can't imagine that they're any more complex and divergent that open vs endoluminal vascular surgery. But assuming your premise is true, why would a single cardiologist have to have both coronary and peripheral skills? Who's to say that cardiology won't become cardiovascular medicine. Some will do coronary intervention fellowships and some will do peripheral intervention fellowships. A 20 man cardiac group could have 10 of each.
Catheter based interventions are an ENORMOUS pile of money laying on the ground ripe for picking up. Cardiologists are not foolish enough to let that business pass them by.
Why ... money, of course.
A cardiology group, especially one with it's own cath facility, would lose a huge amount of money by failing to capitalize on all the peripheral vascular work. Coronary interventions are already a niche pracice along with echo/EP/etc. No reason peripheral vascular would be any different.
You're based in the UK, aren't you? I think you may underestimate the power of economic forces that shape care delivery in the US. "Best care" is a pale 2nd place.
haha yeah, to be fair i forget sometimes that in the states it's all about tha bling
The false ASSumption in this whole argument is that the Cardiologists control the patients.
It is the generalists/family docs that control the patients and refer them. They are the traffic guards in this whole thing. They direct the flow of patients to the subspecialists.
As for the argument that cardiologists manage patients. This is also false. A patient is MANAGED medically by his hospitalist/primary care physician. Even if they refer to a cardiologist, the hospitalist/primary care physician remains on board to medically manage the patient.
It all boils down to who the primary physician/hospitalist will refer for the cases. There is a lot of politicking going on right now by vascular surgeons and interventional radiologists to woo the primary docs.
It is the generalists/family docs that control the patients and refer them. They are the traffic guards in this whole thing. They direct the flow of patients to the subspecialists.
As for the argument that cardiologists manage patients. This is also false. A patient is MANAGED medically by his hospitalist/primary care physician. Even if they refer to a cardiologist, the hospitalist/primary care physician remains on board to medically manage the patient.
It all boils down to who the primary physician/hospitalist will refer for the cases. There is a lot of politicking going on right now by vascular surgeons and interventional radiologists to woo the primary docs.
The idea is not necessarily that cardiologists are getting direct referrals from the FP's for PVD, but that cardiology is already engaged with a very large population of patients at extremely high risk for arterial disease. By the time a patient gets that SFA or carotid stenosis, the cardiologist is often already on board managing the coronary disease. They are already in position to do the SFA since they already have a relationship with the patient.
Obviously you are right that Vascular Surgery is still in a good postion to get many direct referrals from IM and FP. IR not so much, but some are trying to run clinics and cultivate a direct referral base.
graduating vascular surgery fellows today have tremendous opportunities....at least 5 or so openings for every graduate and obviously even more incredible options for those graduating from top fellowships. Starting salaries for top fellowship grads are between 250 and 350 thousand dollars per year. I think we are in the best position to provide the most comprehensive care as we all know that complex problems are often solved by hybrid open and interventional techniques. In the end, it is the vascular surgeon who has ALL the tools to provide the best patient care. I think we'll be OK (off to fellowship in 2008).
I think Vascular Surgery will ultimately be okay too as the SVS gets wiser in its dealings with other subspecialty groups, especially with the cardiologists.
The future of Vascular Surgery will probably be much more interdisciplinary than what we see today. It just has to be when the brass wants to swell our ranks by increasing the number of fellowships and offering all sorts of ways to be trained.
Has the idea of an independent ABVS been dropped because of the availability of the primary certificate?
The idea of an independent ABVS has definitely not been dropped. An independent board seems to be a borderline obsession among some of the leading vascular surgeons (led by Frank Veith). The APDVS (Association of Program Directors in Vascular Surgery) is positively militant about achieving independence. It is still a bitter feud, but there seems to be less open hostility with the primary certificate.
I'm guessing that as more and more people train straight through (3+3 or 0+5) eventually the hybrid General/Vascular surgery practices will go away. At that point, Vascular Surgery will be a separate field and cannot be denied recognition as a separate specialty. Until then, I guess there will continue to be battles.
I'm guessing that as more and more people train straight through (3+3 or 0+5) eventually the hybrid General/Vascular surgery practices will go away. At that point, Vascular Surgery will be a separate field and cannot be denied recognition as a separate specialty. Until then, I guess there will continue to be battles.
Have you ever worked in a Cardiology office? I have two years in a Cardiologist's office and I can tell you for a fact that the Cardiologists are so busy following up on the coronary stuff. Once they are cleared they are sent back to the PCP for the follow up for the other medical conditions. In theory it makes sense that they will do an ABI and work them up for PVD while they are in the office but it doesn't work like that.
IMO the vascular stuff will eventually be owned by vascular surgeons. They will get eventualy get all the direct referrals for these by the FP/IM docs. It is simple as that.
I have. I worked in one for a year. He saw many patients on a recurring basis as did his partners and could have easily screened for PVD. My boss was also an academic who held a prominent national post. At the time, about 10 years ago, he was already starting to talk about moving from cardiology to cardiovascular medicine.
I'm not sure why you think vasc surg will have a lock on referrals from the PCP. PCP's refer to the specialists who are nice to them, nice to patients and see people fast. Whoever gets on the scene fastest with the biggest smile and the most angio rooms is going to get the patients.
An enterprising cards group could easily mop up this business in a given market. If they're too busy now, then they will invest in more partners, NPs, PA's - whatever it takes. I don't think either of our n=1 experiences is very predictive of what an average cards practice can and will do.
I guess I'll have to defer to you with regard to the inner workings of that cardiology office. I don't doubt that lots of cadiologists are plenty busy with coronaries.
But if you think that cardiology is not moving toward the periphery on a national level, then I think you don't understand the situation. I attended TCT (Transcatheter Therapeutics--biggest cardiology meeting on the planet) in 2005 and at least 1/3 of the sessions were on peripheral vascular topics--Carotid stent, endovascular AAA, SFA, iliac, thoracic stent. All done by cardiologists. Many of the largest published clinical series on peripheral intervention have been done by cardiology groups, and virtually all of the major endovascular device trials have significant cardiology involvement. Big cardiology groups dominate device trials for the iliacs and SFA, and their studies dwarf anything in the vascular surgery literature.
Will all this filter down to your average small cardiology group in your average market? Who knows? That's really the big question as far as I'm concerned.
All I can say is that I hope you are right, since I'm just a lowly Vascular Surgeon trying to compete in a tough market.
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Hahaha I take it you have never seen a skilled cardiologist? Catheter based work regardless of location, requires the same skill set. Think about it, after mucking around in 2-3mm cardiac vessels, the majority of the stentable peripheral vascular system is comparable to throwing a toothpick down a hall way - it is simply MUCH easier due to a larger lumen. Now yes, you are right in assuming that a skill must be extensively repeated, but after doing coronaries for 5 years in a busy practice (20+ a week), the skills to migrate to PV work are quick and relatively painless. A few techniques to learn, up and over etc, but it is pretty straight forward.
Sage words from a med-student, you are wise beyond your years. 🙄
And you've never seen a skilled neurointerventionalist.
Riiiiight... I suppose a coronary skills make you well-suited for stenting the basilar artery or coiling an aneurysm.
I have seen skilled cardiologists and one of the reasons why they are so good at what they do is because they have the intelligence to recognise the limits to their abilities and are safe practitioners. Theres a lot more to just performing the procedure. It takes experience through repetition to develop good clinical judgment and take on responsibility. Stenting renal arteries or carotids are not like stenting coronaries. To put it simply if something went wrong everyone would be pointing the finger at the cardiologist and saying you dont stent carotids what the hell were you thinking?! and he/she would be in deep doodoo.
I spend a lot of time in CT surgery and the pure cardiac surgeons I work with dont do any thoracic work (even when on-call). These guys were trained in thoracic surgery and have even passed fellowship exams in the field. However, because they have underdeveloped their clinical judgement in this area they are at a higher risk of making a wrong decision when presented with a complex thoracic case. Ask any pure cardiac surgeon and i'll bet they say the same thing. This is the best analogy I can think of to get my point across.
I've heard of General Surgeon's doing Interventional Radiology fellowships. I'm just curious what your hospital would let you do if you were a GS and a Interventional radiologist. I'm sure they'd let you do CT guided biopsies and drain placements, but would they let you do stenting and stuff like that. I'm actually kind of interested in doing an interventional radiology Fellowship, it could be another way to work some lifestyle into your practice as you wouldn't have to have the patients on your service. Anyone else heard of General Surgeons doing this?
Justin
Justin
An open parathyroidectomy and a lap adrenalectomy aren't remotely alike either, but endocrine surgeons do that all the time. Why? Because they have training and experience in both. There's no reason carotid stent training and experience can't be instilled in cards fellows just as well as vascular fellows
You can find LOTS of examples of a single discipline that performs procedures with highly divergent technical skillsets. Setting aside the issue of a medicine-trained peripheral vascular interventionalist, which I find compelling, I just don't buy your argument that no single person could ever master the wildly divergent task of stenting the LAD and left carotid.
Well like I said before nothing is impossible, there may be a day where one specialty puts stents in every single tube in the body.
My arguments are based on the principle that cardiologists wont take over the field of peripheral stenting because vascular surgery/IR are the ones who currently do these procedures and the main producers of research. This makes these two fields the more likely recipient of a referral. And with this in mind it probably wouldnt be practical to train an interventional cardiologist in peripheral stenting.
But mind you weve already addressed the economic differences between the U.S. and the U.K, so our point of view isnt as money orientated as it is across the pond. Evidence based medicine holds very strong over here. If a cardiologist messed up a peripheral stent they'd have a very hard time justifying why he/she did it in the first place.
Based on what I found out from different sources:
In the near future, the need for vascular surgeons and endovascular surgeries will rise almost exponentially as the population is aging - biggest reason for vascular issues.
Also, vascular surgery itself is evolving with newer techniques being added.
Also, vascular surgeons are a one stop shop when it come to vascular issues - from being PCP to performing surgeries - forming long term relationships.
Not being rude, sarcastic or anything else you can think of,
I have a hard time understanding how interventional radiologists can be as comprehensive as vascular surgeons when it comes to vascular care.
Not every pt. needs surgery - many times, the surgeon can/ will have to also work as a PCP. - more than one option.
Again, PRIMARY FOCUS is vascular care - how about being really interested in vascular issues for the right reasons!
Also, cardiologists being more involved in vascular care seems odd as how will they be able to completely utilize their resources to do so, when the focus of their specialty is the heart!
Stenting, endovascular surgery is not for everyone - a vascular surgeon has more than one technique at his/her disposal to tackle these issues.
Vascular surgeons need to be aggressive and get the word out, people don't know much about what vascular surgeons are capable of.
In a few years, there will be a lot of vascular surgeons with expertise in endovascular surgery to keep the show running .
Last but not the least , who are the only people that are called surgeons - one of the most exciting fields out there!!!
In the near future, the need for vascular surgeons and endovascular surgeries will rise almost exponentially as the population is aging - biggest reason for vascular issues.
Also, vascular surgery itself is evolving with newer techniques being added.
Also, vascular surgeons are a one stop shop when it come to vascular issues - from being PCP to performing surgeries - forming long term relationships.
Not being rude, sarcastic or anything else you can think of,
I have a hard time understanding how interventional radiologists can be as comprehensive as vascular surgeons when it comes to vascular care.
Not every pt. needs surgery - many times, the surgeon can/ will have to also work as a PCP. - more than one option.
Again, PRIMARY FOCUS is vascular care - how about being really interested in vascular issues for the right reasons!
Also, cardiologists being more involved in vascular care seems odd as how will they be able to completely utilize their resources to do so, when the focus of their specialty is the heart!
Stenting, endovascular surgery is not for everyone - a vascular surgeon has more than one technique at his/her disposal to tackle these issues.
Vascular surgeons need to be aggressive and get the word out, people don't know much about what vascular surgeons are capable of.
In a few years, there will be a lot of vascular surgeons with expertise in endovascular surgery to keep the show running .
Last but not the least , who are the only people that are called surgeons - one of the most exciting fields out there!!!
"Based on what I found out from different sources:
In the near future, the need for CARDIOLOGISTS and endovascular INTERVENTIONS will rise almost exponentially as the population is aging - biggest reason for vascular issues.
Also, CARDIOLOGY itself is evolving with newer techniques being added.
Also, CARDIOLOGISTS are a one stop shop when it come to vascular issues - from being PCP to performing interventions - forming long term relationships.
Not being rude, sarcastic or anything else you can think of,
I have a hard time understanding how vascular surgeons can be as comprehensive as cardiologists when it comes to vascular care.
Not every pt. needs surgery.
Again, PRIMARY FOCUS is vascular care - how about being really interested in vascular issues for the right reasons!
Also, cardiologists being more involved in vascular care seems natural when the focus of their specialty is the cardiovascular system! "
---
This is the exact argument cardiologists have used. In Texas, where I'm from, cardiology dominates peripheral vascular disease in mid-sized to large cities.
I got news for you-- cardiologists will eat your lunch. They drove CT surgeons to the brink. Now the specialty is called 'Thoracic Surgery'. Don't think it can't happen to you. They already dominate renal stenting (as far as #s/year) and are well invested in aortic-stent grafts and will soon rule carotid stenting and don't be surprised to see them try to get into stroke interventions in the future.
Peripheral vascular will be about 15% of my practice. If I lose peripheral vascular work, so what? We have more than enough onc, uro, gi, gyn, spine and other bread and butter cases to pack my schedule, not to mention any of the newer procedures being developed. OTOH, vascular disease will be your livelihood. I have no beef with vascular surgeons doing what they need to do to survive.
Surgluv, If you think IR is your enemy, you're missing the forest for the trees.
In the near future, the need for CARDIOLOGISTS and endovascular INTERVENTIONS will rise almost exponentially as the population is aging - biggest reason for vascular issues.
Also, CARDIOLOGY itself is evolving with newer techniques being added.
Also, CARDIOLOGISTS are a one stop shop when it come to vascular issues - from being PCP to performing interventions - forming long term relationships.
Not being rude, sarcastic or anything else you can think of,
I have a hard time understanding how vascular surgeons can be as comprehensive as cardiologists when it comes to vascular care.
Not every pt. needs surgery.
Again, PRIMARY FOCUS is vascular care - how about being really interested in vascular issues for the right reasons!
Also, cardiologists being more involved in vascular care seems natural when the focus of their specialty is the cardiovascular system! "
---
This is the exact argument cardiologists have used. In Texas, where I'm from, cardiology dominates peripheral vascular disease in mid-sized to large cities.
I got news for you-- cardiologists will eat your lunch. They drove CT surgeons to the brink. Now the specialty is called 'Thoracic Surgery'. Don't think it can't happen to you. They already dominate renal stenting (as far as #s/year) and are well invested in aortic-stent grafts and will soon rule carotid stenting and don't be surprised to see them try to get into stroke interventions in the future.
Peripheral vascular will be about 15% of my practice. If I lose peripheral vascular work, so what? We have more than enough onc, uro, gi, gyn, spine and other bread and butter cases to pack my schedule, not to mention any of the newer procedures being developed. OTOH, vascular disease will be your livelihood. I have no beef with vascular surgeons doing what they need to do to survive.
Surgluv, If you think IR is your enemy, you're missing the forest for the trees.
B
Blade28
No one is handing over patients to Cardiologists. I am stating the cardiologist's rationale for getting into your livelihood stent-grafts, fem and infra pop interventions, carotid and renal work. I never said I agreed with that position.
You may actually want to read my post before you transfer your patients. Lest a fool and his livelihood soon be parted.
As a general surgery resident and interested in vascular surgery and endovascular issues, i find this discussion very awckward. Having read this thread, it seems completely strange to me to see that cardiologists are taking this field from the vascular surgeon. From my point of view, and from the hospital in which i'm training, where almost all residents in vascular surgery do 1 or 2 years extra in endovascular and angioradiography, they come out really prepared for it.
Of course there is a multidisciplinary team, but i believe that the opinion in general is that you must, or at least be prepared, for the complications/post-op care/follow-up of the treatment you propose for the patient, and in this field the surgeon with endovascular training is the first choice for PVD. I wouldn't, in my personal opinion, send a patient for a cardio or a radio to do a peripheral vascular stenting, for being referred back after a few years to do the bypass! At least in Brazil, or the state i live, vascular surgeons don't agree with this type of attitude.
just my 2 cents.
Of course there is a multidisciplinary team, but i believe that the opinion in general is that you must, or at least be prepared, for the complications/post-op care/follow-up of the treatment you propose for the patient, and in this field the surgeon with endovascular training is the first choice for PVD. I wouldn't, in my personal opinion, send a patient for a cardio or a radio to do a peripheral vascular stenting, for being referred back after a few years to do the bypass! At least in Brazil, or the state i live, vascular surgeons don't agree with this type of attitude.
just my 2 cents.
You should probably understand that in the United States, presumably unlike Brazil, some physicians -- especially cardiologists -- are motivated by and stretch indications for the all mighty dollar bill.
It's what gives them the right to treat TASC D lesions with stents from the aortic bifurcation through the entire SFA.
And then, when these "full metal jackets" occlude, guess who will be stuck trying to figure out how to revascularize the poor bastard? Yep, you guessed it. The scalpel jock.
If you're a cardiologist, the patient's well being and your professional ethics are checked in at the door. Welcome to America.
At least vascular surgeons will still have diabetic foot care.
How much endovascular work is done by vascular surgeons will depend largely on referral patterns in a hospital system. When will PCPs start referring claudication patients to cardiologists instead of vascular surgeons?
It's not hard to imagine a future where vascular surgeons finally get to see a patient only after multiple angioplasties, and stents, that cardiologists have placed. Kinda like the patients that CT surgeons evaluate for CABGs that have completely stented out coronaries with nowhere to bypass to.
I sincerely hope this does not happen.
How much endovascular work is done by vascular surgeons will depend largely on referral patterns in a hospital system. When will PCPs start referring claudication patients to cardiologists instead of vascular surgeons?
It's not hard to imagine a future where vascular surgeons finally get to see a patient only after multiple angioplasties, and stents, that cardiologists have placed. Kinda like the patients that CT surgeons evaluate for CABGs that have completely stented out coronaries with nowhere to bypass to.
I sincerely hope this does not happen.
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No, it's certainly not hard to imagine.
However I think drawing on the experiences of CT surgeons and how they were muscled out of a lot of issues with coronary stenting, Vascular Surgery is doing a fairly good job in keeping involved with endovascular stuff and ensuring that it'll still have a place in the future of peripheral vascular care. The integrated programs are a great start to attract more people into the profession.
In the end of course, cardiologists outnumber vascular surgeons by a lot and I'm sure if they could, they'd relegate most vascular surgeons to the sidelines to wait for that disaster or a full metal jacket.
I, too, hope this doesn't happen. That's why educating the PCPs and keeping them happy is all-important in this game.
True, I saw some cards group offering generous amount of salary to hire a vascular surgeon to join them
That's a sucker bet if I've ever seen one. Yet I'm sure there's some ***** out there who's thinking, "Gee, that seems like a good deal. I'd like to be a ***** too."
in face of half million bucks? some one will sell their soul. there are enough doctors out there act as expert witness to screw their colleagues.
What about neurovascular stuff? Is the same sort of battle taking place between IR and Neuro?
