Why does vascular surgery get bad rap?

[NY172]

Whenever I tell physicians I am interested in vascular surgery, almost always I hear, "don't do it". I was wondering why the specialty has such a negative reputation? Would anyone be willing to shed some light on this perception? Sure, the hours are long and the patient base has its issues, but I feel the same could be said for many fields in medicine.

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[LucidSplash]

Whenever I tell physicians I am interested in vascular surgery, almost always I hear, "don't do it". I was wondering why the specialty has such a negative reputation? Would anyone be willing to shed some light on this perception? Sure, the hours are long and the patient base has its issues, but I feel the same could be said for many fields in medicine.

Famously long hours with lots of emergencies, very sick patients essentially without a true cure, high rate of recitivism/noncompliance.

I love it and tend to think of it as job security. But it isn’t for everyone.

 

[evilbooyaa]

You have to be mentally prepared that a fair number of patients that you are doing heroic operations for will continue cheeseburgering and smoking their way to an amputation.... that you will also do. And then wound care management of that non-healing amputation you did.

Or that your patients are idiots - for example, the guy who doesn't want his giant AAA repaired electively... and then it starts leaking and the ER calls for emergency surgery.

And yeah, the lifestyle isn't great, from general emergencies (cold foot, vascular trauma, etc.) to iatrogenic emergencies (Cards or IM whoever else in the hospital is having misadventures in the vasculature), there's a lot of stuff to go around.

Vascular was by far the busiest rotation which sucked as an intern as well.

 

[HighPriest]

They're always selling drugs under the bleachers and drag racing.

 

[OrthoTraumaMD]

I was once told by an attending, “the vascular patients don’t get better, they just get shorter.” (I.E. amputation)


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[thedrjojo]

Also, it's becoming more and more endovascular heavy which is a) not everyone's ideal of 'surgery' and b) allows competitive creep... Ir and even cards have been known to do some peripheral arterial stuff.

 

[TypeADissection]

I was once told by an attending, “the vascular patients don’t get better, they just get shorter.” (I.E. amputation)

I love this so much I'm stealing it and claiming it as my own.

To the OP: I think vascular surgery as a field tends to attract a certain kind of person. My generation that is going through it right now is young, energetic and quite passionate about the field. Here's an article about random musings on a "vascular surgery gene." An article more for fun than anything else, but it is a field that has its own set of rewards. The SVS and loco-regional societies usually have traveling scholarships to attend annual meetings and see current research and meet the people. As a subspecialty, it's rather small with only around maybe 3000-3500 practitioners nationwide. But if you're interested, you should explore it and see if it's for you. I'd much rather be in the hospital late doing a vascular case than an appy, hot gallbag or butt stuff. Cheers.

 

[SLUser11]

Also blood is icky....gross!

 

[Psai]

Also, it's becoming more and more endovascular heavy which is a) not everyone's ideal of 'surgery' and b) allows competitive creep... Ir and even cards have been known to do some peripheral arterial stuff.

lol at claiming that IR is the one creeping

 

[doc05]

I'd much rather be in the hospital late doing a vascular case than an appy, hot gallbag or butt stuff. Cheers.

Why would you want to be in the hospital late?

 

[doc05]

Whenever I tell physicians I am interested in vascular surgery, almost always I hear, "don't do it". I was wondering why the specialty has such a negative reputation? Would anyone be willing to shed some light on this perception? Sure, the hours are long and the patient base has its issues, but I feel the same could be said for many fields in medicine.

Because of long operations, long hours, working on very very sick patients who never really get better.

 

[TypeADissection]

Why would you want to be in the hospital late?

I don't. But if I'm in the hospital instead of home with my hot wife and dope son, I'd rather have it be because I'm fixing an aneurysm or cold limb. You know what I don't want to be in the hospital for? Fournier's, dislodged enteric feeding tubes, free air, diverticulitis, appys, gallbags, basically anything within general surgery. We all choose to dance with a devil, mine is all about the vessels.

 

[NY172]

thanks for all the feedback. im debating between vascular surgery and anesthesiology and just about everyone says anesthesia hands down...i think i know why.

 

[Winged Scapula]

Also blood is icky....gross!

So. says the poop surgeon.

 

[Southpaw]

thanks for all the feedback. im debating between vascular surgery and anesthesiology and just about everyone says anesthesia hands down...i think i know why.

Head over to the anesthesiology forum and ask us. You'll get varied responses (mostly negative!) and I readily admit anesthesiology isn't all sunshine and rainbows. Personally, anesthesiology is good field of medicine and I enjoy it but there's a lot to be said for ownership of patients which surgeons wrote the book on. I also find the personalities of anesthesiology and vascular surgery to be vastly different, but my personal n isn't very large. I considered orthopedics but decided late to go into anesthesiology. I didn't consider vascular surgery, but the increase in endovascular is cool I think. If only they could keep the damn cardiologists from trying to stent everything they see.

 

[VascularMan]

Here's why I love vascular - there's a wide variety of procedures you can do on essentially the entire human body, and the open procedures were the most fascinating and delicate I've seen in surgery (carotid, open AAA, NAIS procedure, bypasses,etc). There are also endovascular options for patients who can't undergo surgery, and you'll watch your patients do much better from these options rather than having to wack them open all the time. At the end of the day, you want to do what's best for your patient and we have both surgical and endo options. And yes, the patients have chronic issues that you take care of over a period of time, but that allows you to build long-lasting relations with them and their families and make a huge impact. There's also an incredible feeling of satisfaction when walking into an OR and repairing damage caused by other surgeons who knicked a vessel intraoperatively, with blood pooling everywhere, and rely on you to save their patient.

People talk about IR and cardiologists doing endovascular procedures, and the vascular surgeons certainly don't feel threatened by this. For one, vascular has taken complete control of the field and offer all the specific training for it, whereas you don't see that stuff in IR or cards training programs. Also, with our aging population, vascular surgery will continue to have the greatest need per provider (for the next 30 years), so there certainly won't be a shortage of cases even if anyone tries to steal cases from us.

 

[MediCane2006]

Whenever I tell physicians I am interested in vascular surgery, almost always I hear, "don't do it". I was wondering why the specialty has such a negative reputation? Would anyone be willing to shed some light on this perception? Sure, the hours are long and the patient base has its issues, but I feel the same could be said for many fields in medicine.

Go read the last couple pages of the consult thread....

 

[Psai]

I don't get why all vascular trainees have this weirdo notion that their field owns endovascular techniques. You are the thieves

 

[LucidSplash]

I don't get why all vascular trainees have this weirdo notion that their field owns endovascular techniques. You are the thieves

Its more that we have the ability to choose the best treatment for the patients (Endo vs open) because we have the complete skill set. I’m being trained to do this in fellowship so I’m not stealing it from anyone; the techniques are firmly established in vascular training at this point over multiple generations AND we are the ones driving newer tech. IR and cards may do the peripheral and aortic endo procedures but it’s the only trick in their bag so to speak. If something goes wrong during Endo, I can fix it myself open. I don’t need to call the CT or vascular surgeon on backup.

 

[ThoracicGuy]

Its more that we have the ability to choose the best treatment for the patients (Endo vs open) because we have the complete skill set. I’m being trained to do this in fellowship so I’m not stealing it from anyone; the techniques are firmly established in vascular training at this point over multiple generations AND we are the ones driving newer tech. IR and cards may do the peripheral and aortic endo procedures but it’s the only trick in their bag so to speak. If something goes wrong during Endo, I can fix it myself open. I don’t need to call the CT or vascular surgeon on backup.

Do they send you many pseudoaneurysms?

 

[LucidSplash]

Do they send you many pseudoaneurysms?

Constantly from cards. Especially the day after TAVR day.

 

[ThoracicGuy]

Constantly from cards. Especially the day after TAVR day.

And I'm guessing they never use ultrasound for access...

 

[LucidSplash]

And I'm guessing they never use ultrasound for access...

I'm guessing not by the percentage of high sticks and bleeding into the retroperitoneum... and use of angioseal in highly calcified arteries.

 

[ThoracicGuy]

I'm guessing not by the percentage of high sticks and bleeding into the retroperitoneum... and use of angioseal in highly calcified arteries.

And if someone had a prosthetic graft in the right groin but a clean left side, they still stick the right side... IR at my place rarely gives us issues, but cardiology? It's just horrible.

 

[LebronManning]

What do you all expect the percentage of open to endo vascular surgery will be 15-20 years from now?

 

[LucidSplash]

What do you all expect the percentage of open to endo vascular surgery will be 15-20 years from now?

Depends on the outcome of the BEST trial and a few other studies in the works.

 

[mimelim]

I don't get why all vascular trainees have this weirdo notion that their field owns endovascular techniques. You are the thieves

I have 5 years of endovascular specific training under my belt. I have a huge amount of respect for many IR and IC guys that I have met and sometimes trained under. Their vast wealth of experience and leadership make them fantastic clinicians. But, lets not pretend that current IR or IC training is remotely close to that of vascular surgery. Take for example IC. We have one of the largest and one of the best respected Cardiology and Interventional Cardiology fellowships in the country. They spend 3 years doing IM, 3 years doing Cardiology and then a year of IC. Total time spent in the cathlab? 15 month? Granted, in my 5 years, my intern year I operated a lot less than I do now, but regardless, by the time residents hit the middle of year 3, they comfortably have done more angios than graduating IC fellows.

Constantly from cards. Especially the day after TAVR day.

We now do TAVRs 3 days a week, July we go to 4 days a week. Not long, every day will be TAVR day. Open repair of femoral vessels, no longer weekly, soon to be daily.

 

[doc05]

Depends on the outcome of the BEST trial and a few other studies in the works.

Keep telling yourself that. No matter what the results, it will be about 90% Endovascular, because that's what patients and referring docs want.

 

[LucidSplash]

Keep telling yourself that. No matter what the results, it will be about 90% Endovascular, because that's what patients and referring docs want.

Well since we are all looking into a crystal ball, who knows.

But I do know we are doing far fewer CEAs than we were 15-20 years ago, which is a data-driven shift in management. And we are doing very few carotid stents, despite all the predictions that stents would replace CEA. Again, because of data-driven practice.

I would hope that if the trials looking at peripheral endo vs open bypass clarify which patient populations and anatomy are best suited for each, then we would again be on the forefront of educating referring physicians and patients about data-driven management.

But like I said, crystal balls and all.

 

[AdmiralChz]

woman ended up using 31(!) units of blood

You’ll see a lot more than that with some emergencies they Vascular deals with.

 

[DarknightX]

Keep telling yourself that. No matter what the results, it will be about 90% Endovascular, because that's what patients and referring docs want.

That would be true if 90% of peripheral vascular disease was amenable to endovascular treatment. But there are lesions that can't be treated endovascularly. If you can't get a wire across it, then it doesn't matter what the patients or the referring doc wants.

I'd much rather due an endovascular procedure for a patient under MAC and local, then subject a patient who likely has significant CAD to a general anesthetic, but sometimes that just isn't possible. Many of the patients that we bypass have had prior endovascular procedures and attempts, and bypass is the next option for them. If it was that simple to get a wire across any occlusion, then 100% of patients would undergo endovascular therapy.

But that isn't reality.

I just had a lady with very high cardiac risk that I tried to do endo. Total SFA occlusion. First attempt was from above, second attempt was from below the knee pop. I even sent her to my IR colleagues to attempt tibial access, but couldn't be done. She has critical limb ischemia and bypass is her only option. There are many cases like this.

 

[Jolie South]

That would be true if 90% of peripheral vascular disease was amenable to endovascular treatment. But there are lesions that can't be treated endovascularly. If you can't get a wire across it, then it doesn't matter what the patients or the referring doc wants.

I'd much rather due an endovascular procedure for a patient under MAC and local, then subject a patient who likely has significant CAD to a general anesthetic, but sometimes that just isn't possible. Many of the patients that we bypass have had prior endovascular procedures and attempts, and bypass is the next option for them. If it was that simple to get a wire across any occlusion, then 100% of patients would undergo endovascular therapy.

But that isn't reality.

I just had a lady with very high cardiac risk that I tried to do endo. Total SFA occlusion. First attempt was from above, second attempt was from below the knee pop. I even sent her to my IR colleagues to attempt tibial access, but couldn't be done. She has critical limb ischemia and bypass is her only option. There are many cases like this.

Not to mention some people are best treated by hybrid options also. We are running a special on common femoral endarterectomy with antegrade SFA interventions this week.

I think what's great about vascular is that there is a lot of middle ground where you can go a multitude of ways to fix somebody and it's based on the patient, what the patient wants, what the patient's comorbidities are, and the lesion you're dealing with. It's not a one size fits all specialty.

I think when you have all the tools at your disposal, you're not in the "when all you have is a hammer, everything looks like a nail" scenario. We do what's in the patient's best interest because we aren't limited by inability to open the groins or do a bypass or a hybrid approach.

It is a very different mentality to general surgery where if you have an appendix problem, you get an appendectomy or a gallbladder problem, you get a chole. There are multiple acceptable solutions to certain problems especially in lower extremity occlusive disease.

 

[Dr.LeoSpaceman]

It is a very different mentality to general surgery where if you have an appendix problem, you get an appendectomy or a gallbladder problem, you get a chole. There are multiple acceptable solutions to certain problems especially in lower extremity occlusive disease.

I get it...you're a vascular fellow who loves vascular. "It's just another gallbladder" is how people show up at a referral center with a CBD injury. Out of the past 8 or 9 choles I've done, half of them have had some variant that's made them challenging and made me do something a bit different. The lack of a "one size fits all" approach to surgical disease isn't unique to vascular...it's shared by essentially all surgical subspecialties.

 

[Jolie South]

I get it...you're a vascular fellow who loves vascular. "It's just another gallbladder" is how people show up at a referral center with a CBD injury. Out of the past 8 or 9 choles I've done, half of them have had some variant that's made them challenging and made me do something a bit different. The lack of a "one size fits all" approach to surgical disease isn't unique to vascular...it's shared by essentially all surgical subspecialties.

My point was not to minimize anyone or say that a chole is just a chole. I have done a number of very difficult choles in residency and I have had to take care of CBD injuries with our transplant service.

I am saying that you have someone with cholecystitis and you’re going to do a cholecystectomy. Not have a decision tree that involves 3 potential alternatives. While you might treat initially with a cholecystostomy tube if they are super sick, the final common pathway for that disease process involves cholecystectomy.

 

[Dr.LeoSpaceman]

My point was not to minimize anyone or say that a chole is just a chole. I have done a number of very difficult choles in residency and I have had to take care of CBD injuries with our transplant service.

I am saying that you have someone with cholecystitis and you’re going to do a cholecystectomy. Not have a decision tree that involves 3 potential alternatives. While you might treat initially with a cholecystostomy tube if they are super sick, the final common pathway for that disease process involves cholecystectomy.

The counter factual, at least for me personally, is that I don't necessarily enjoy a decision tree that ends on something where it's unclear what the "best" procedure is. Of course, that also provides benefit for the academically inclined to answer those questions.

As an aside to something earlier in the thread regarding who stole interventional procedures from whom, I just saw this: Avenu – Ellipsys – Avenu Medical

If I were a marketing guy, perhaps I'd summarize their pitch as "Durable dialysis access so easy a radiologist can do it!"

 

[ThoracicGuy]

The counter factual, at least for me personally, is that I don't necessarily enjoy a decision tree that ends on something where it's unclear what the "best" procedure is. Of course, that also provides benefit for the academically inclined to answer those questions.

As an aside to something earlier in the thread regarding who stole interventional procedures from whom, I just saw this: Avenu – Ellipsys – Avenu Medical

If I were a marketing guy, perhaps I'd summarize their pitch as "Durable dialysis access so easy a radiologist can do it!"

That device looks terrible. Nearly all of their patients required secondary procedures to make the fistula usable.

 

[CaptainSSO]

I'm guessing not by the percentage of high sticks and bleeding into the retroperitoneum... and use of angioseal in highly calcified arteries.

To be fair I don’t really think ultrasound prevents high sticks...mainly that’s a function of where the femoral head is in relation to your arteriotomy. At least that’s how we aim our sticks on IR.

 

[DarknightX]

To be fair I don’t really think ultrasound prevents high sticks...mainly that’s a function of where the femoral head is in relation to your arteriotomy. At least that’s how we aim our sticks on IR.

I have to respectfully disagree with that. If you use ultrasound, you can identify the bifurcation of the common femoral artery and the profunda, and stick right above that. You can also see where the CFA starts to dive under the inguinal ligament. Although anecdotal, I’ve never had to bail out anyone who used ultrasound routinely for femoral access.

I routinely have to bail out cardiologists and interventionalists who don’t use ultrasound. I see at least 6 iliac injuries a year, and all were with older guys who stubbornly refuse to use ultrasound.

 

[LucidSplash]

I have to respectfully disagree with that. If you use ultrasound, you can identify the bifurcation of the common femoral artery and the profunda, and stick right above that. You can also see where the CFA starts to dive under the inguinal ligament. Although anecdotal, I’ve never had to bail out anyone who used ultrasound routinely for femoral access.

I routinely have to bail out cardiologists and interventionalists who don’t use ultrasound. I see at least 6 iliac injuries a year, and all were with older guys who stubbornly refuse to use ultrasound.

All of this. I just haven’t had time to respond thoughtfully. Thanks.

 

[Smurfette]

I have to respectfully disagree with that. If you use ultrasound, you can identify the bifurcation of the common femoral artery and the profunda, and stick right above that. You can also see where the CFA starts to dive under the inguinal ligament. Although anecdotal, I’ve never had to bail out anyone who used ultrasound routinely for femoral access.

I routinely have to bail out cardiologists and interventionalists who don’t use ultrasound. I see at least 6 iliac injuries a year, and all were with older guys who stubbornly refuse to use ultrasound.

Speaking of iliac injuries, this reminded me of a posterior spine procedure where intraop they injured the back of the iliac. Thankfully a rare albeit known complication. They called for help but had to close up the back, flip the patient, and do an anterior approach to control the bleeding. EBL was like 5L. Thankfully the patient recovered but had some bad lymphedema (2/2 venous stenosis) a few weeks later.

 

[LucidSplash]

Speaking of iliac injuries, this reminded me of a posterior spine procedure where intraop they injured the back of the iliac. Thankfully a rare albeit known complication. They called for help but had to close up the back, flip the patient, and do an anterior approach to control the bleeding. EBL was like 5L. Thankfully the patient recovered but had some bad lymphedema (2/2 venous stenosis) a few weeks later.

We can stent that too. Doing a lot of iliac vein stents for symptomatic stenosis these days...

 

[CaptainSSO]

I have to respectfully disagree with that. If you use ultrasound, you can identify the bifurcation of the common femoral artery and the profunda, and stick right above that. You can also see where the CFA starts to dive under the inguinal ligament. Although anecdotal, I’ve never had to bail out anyone who used ultrasound routinely for femoral access.

I routinely have to bail out cardiologists and interventionalists who don’t use ultrasound. I see at least 6 iliac injuries a year, and all were with older guys who stubbornly refuse to use ultrasound.

Interesting, thanks for your insight. I train at a place that’s fairly old school so that’s how I’ve been taught. But in the future and especially for my own practice down the line I’ll keep that in mind.