why dont CT surgeons learn PCI and other catheter base procedures?

[copacetic]

why dont CT surgeons learn PCI and other catheter base procedures?

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[WDeagle]

Even if CT surgeons learned PCI they would still need cardiologists and internists to refer patients to them. Interventional Cardiologists arent going to refer patients to the CT surgeons because they can do it themselves. General cards and IM are probably more likely to refer to interventional cards then PCI trained CT surgeons.

 

[Krazykritter]

PCI's rather short history has been a turf war almost it's entire existence. Originally, interventional radiologists were performing these procedures under the guidance of cardiologists.

Cardiologists realized that there was money to be made so they began training in performing interventions (they had previously only been performing angiograms). The turf war ensued between IR & Cardio with cards obviously coming out ahead on that, but IMO IR would have given up this due once PCI won it's place in acute MI requiring 24/7 call.

You also have to realize that coronary angiography originally had no role in the acute setting. Angiography was actually around for quite a while before balloons were even used in the setting of angioplasty. In fact, before we realized that the thrombus occurs acutely & itself the cause of AMI in many cases, cardiologists & CV surgeons alike were taught that the thrombus was a result of the MI.

Pioneers in interventional cardiologist began taking patients to the cath lab, shooting the coronaries & then passing them to their CV colleagues for acute bypass in acute MI. The two fields have worked hand-in-hand for decades & it would be tough on the necessary relationship that these physicians must have if everyone was encroaching on the other's turf.

 

[ESU_MD]

As a general surgery resident, I have to admit I thought the same thing myself.. why dont CV surgeons do caths?

Well, as I grow older and became a CV surgery resident- I realize the reason is ultimately- most CV surgeons dont WANT to do caths.

No surgeon WANTSto take all the cath calls from the ER all night, or spend 2 days a week doing elective caths during the week. there isnt enough time..

Of course, CV surgeons are gettin involved in endovascular stenting of the aorta and other peripheral vessels, but starting to stent coronaries?-- may be more than we wished for. despite what you think- there are enough CAB's and valves to keep busy (for now)

As everyone knows, even the drug eluting stents are not the miracle device everyone hoped for, thus CABG is still the gold standard for cardiac revascularization.

no stent will rival the patency of the LIMA-LAD graft. EVER

besides. the VAST MAJORITY of interventional cards guys I've met are not interested in "taking over." yes- there are a few a-holes who want to stent left mains and drop stents in 3 vessel disease, but these are the minority who will ultimately be flushed out of the system.

 

[JackADeli]

why dont CT surgeons learn PCI and other catheter base procedures?

Actually, CV surgeons are getting involved in catheter based procedures at an increasingly higher number. The presence of such traing is a market factor at some programs. It is not coronary PCI however. They are increasingly learning aortic stenting, etc.... They are also learning skills for transapical and endovascular aortic valve replacement/implantation. There exist min-fellowships just for this training. They can be as short as a few weeks, months, or even a year long. You can find some listed on CTSNet.

....no stent will rival the patency of the LIMA-LAD graft. EVER....

That is a pretty bold statement that I would not be willing to predict the future and make. Some years back, CV surgeons laughed folks out of the room that talked about coronary stenting. Now, I hear CV surgeons all the time looking at caths and asking the cards guy, "I think you can stent that lesion, right?", or "can we do a hybrid procedure with you stenting that and I will do a MIS procedure for this".

I think stenting is here to stay. What future chemical and biological devices are deployed in which vessels one can only guess.

...yes- there are a few a-holes who want to stent left mains and drop stents in 3 vessel disease, but these are the minority who will ultimately be flushed out of the system...

When stenting came out, everyone predicted failure and job loss for those "cowboys". There were numerous unfortunate events. I suspect the incidence of groin complications and coronary dissections were probably higher in the beginning. Nonetheless, those individuals pushing the envelope have helped advance the field of cardiac care. In similar fashion, Individuals that started pushing some early "NOTES" have been laughed at, lost their jobs... only to find themselves as the "leaders" and some heading up "MIS" programs at different institutions. I know of a "big name surgeon" at a "big name University Med Ctr" that does only OPEN Nissens and continually bad mouths laparoscopy. The truth is, such individuals with such closed minded perspectives and/or tunnel vision inhibit medical progress.

I am not sure we can say anyone stenting an LAD "will ultimately be flushed out of the system..." Again, what future chemical and biological devices are deployed in which vessels one can only guess.

JAD

 

[pRotAgOnIsT]

Of course, CV surgeons are gettin involved in endovascular stenting of the aorta and other peripheral vessels, but starting to stent coronaries?-- may be more than we wished for. despite what you think- there are enough CAB's and valves to keep busy (for now)

no stent will rival the patency of the LIMA-LAD graft. EVER

I'm sure that you are aware of the moves that vascular surgery leadership is advancing that will box cardiac surgeons out of endovascular therapy. Hospitals are going to fall in line with SVS guidelines (or proposed ones) that essentially will make it very hard/impossible for non-fellowship trained vascular surgeons to get privileges to do any catheter work.

It's conceivable that cardiac surgeons will get "involved" in TEVARs. At my institution, the cardiac guys are just now learning TEVAR from the vascular surgeons. We have pgy-3s that have done more TEVARs than any of our cardiac surgeons. Endovascular peripheral work? It's way too late for that. The cardiac surgeons have already missed the boat on that one.

Oh, and how do you know the LIMA graft will remain superior for "EVER"? I'm guessing that the cardiac surgeon in 1985 thought that CABG would never be replaced by anything, "EVER" as well.

 

[JackADeli]

I'm sure that you are aware of the moves that vascular surgery leadership is advancing that will box cardiac surgeons out of endovascular therapy. Hospitals are going to fall in line with SVS guidelines (or proposed ones) that essentially will make it very hard/impossible for non-fellowship trained vascular surgeons to get privileges to do any catheter work.

It's conceivable that cardiac surgeons will get "involved" in TEVARs...

Remember, a good percentage of vascular surgery done in the community is done by bread and butter trained general surgeons with no vascular or CT/CV fellowship training.

I am certain every specialty thinks they will "box X surgeons out". However, as long as CV programs are interested and involved in thoraco-abdominal aortic surgery, it is hard to see vascular surgery locking them out. It will be hard for vascular surgeons (leadership or not) to make the argument that they should decide who does thoracic aortic procedures and that cardiac trained surgeons are unqualified (while vascular surgeons do not have the capacity/training to go on bypass to replace an arch/etc). Hybrid CV OR's are being deployed. Cardiac surgeons are doing thoracic aortic stenting in dissections, aneurysms, and trauma.
Cardiac surgeons are performing "arch first" procedures and then returning for the thoracic stent component. There are numerous "mini-fellowships". If cardiac surgeons get "box out", it will because they choose not to get involved.... not because "vascular surgery leadership" has done something. The "box out" claims are marketing to recruit to each subspecialty.

http://www.sts.org/sections/education/Endovascular%20Training%20Opportunities/

...Endovascular peripheral work? It's way too late for that. The cardiac surgeons have already missed the boat on that one...

While I can't speak for anyone else, IMHO, I'm not sure they ever wanted to be on the "cold foot" or "gangrene toe" boat.


JAD

 

[pRotAgOnIsT]

JAD,

I think that CT surgeons should definitely be doing thoracic endografts. No question about it. But how many trainnig programs in the US right now are giving their trainees endovascular training? The CT surgeons should be the ones developing this technique and leading the way. Going to a "minifellowship" to learn TEVAR from a vascular surgeon/cardiologist/company rep is a little sad. The CTS leadership should be all over this, but it is not.

You posted: "It will be hard for vascular surgeons (leadership or not) to make the argument that they should decide who does thoracic aortic procedures and that cardiac trained surgeons are unqualified (while vascular surgeons do not have the capacity/training to go on bypass to replace an arch/etc)."

It is not very hard to believe at all actually. When I watch one of our CT surgeons fumbling around with the wires during a TEVAR that one of our vascular surgeons is taking him through, it's startling. Just because a CT surgeon is experienced at open thoracic aorta repair does not qualify him/her in the least for an endovascular repair of that same lesion. The skill sets are totally different. By your logic, cardiologists should not be doing PCI. Actually the CT surgeons may be the last folks in the room to realize that cardiologists, vascular surgeons, and interventional radiologists, all have no problem doing these procedures on their own, and having a CT surgeon on call in case the aorta is injured. Sound familiar?

Anyhow, my previous post was in response to ESU's comment that CT surgeons will be "stenting...other peripheral vessels".

 

[JackADeli]

...I think that CT surgeons should definitely be doing thoracic endografts...how many trainnig programs in the US right now are giving their trainees endovascular training?...When I watch one of our CT surgeons fumbling around with the wires during a TEVAR...The skill sets are totally different. By your logic, cardiologists should not be doing PCI...Anyhow, my previous post was in response to ESU's comment that CT surgeons will be "stenting...other peripheral vessels".

I appreciate you sentiments. I view it from a different perspective with some historical consideration. For example:

When laparoscopy first came out....
Most if not all attendings and especially senior attendings in all honesty just sucked and possibly dangerous by todays standards! A lap chole was actually a chief resident case. Now, a community program trained intern is probably capable of doing a straightforward Lapchole in under an hour... safely! Thus, it is now an "basic laparoscopy" case. How did folks learn if their seniors didn't know how to do it safely and even less capable of teaching it? Sound like a familiar argument?

Currently, a good amount of vascular is done in the community by general surgeons without formal vasc fellowship...fact. Look up for jobs and general surgery groups are looking for more general surgery grads with "vascular experience" and "endovascular experience".

A good many gray hairs have no interest in endovasc or learning endovasc. Junior attendings have limited experience but many have interest. Numerous current residents have interest. It is just a backfill situation if you will. The ABTS (i.e. leadership) does see the importance and is pushing the issue. Med Ctrs are investing millions of dollars into "hybrid" CV-ORs. You just do not have the broad "brain Base" educational foundation yet. As an interim, you have 3+ month mini-fellowships at places like Stanford, Cleveland Clinic, etc... You do upwards of 20+ procedures a week including periph vascular ( you can check out STS link in my previous post). It may take five or so years to allow accumulation of new attendings and retirement of gray hairs as their 401Ks recover with the economy.

As for different skill set.... well there maybe some particulars but it's not rocket science or differential equations. I have seen folks fumble with wires when placing a subclavian line. Let's not try and make this out to be some magical and complex procedure. If you do 20 cases a week over 3+ months and in addition you are already trained to perform vascular anastamosis of 1.5mm, I'm sure you'll do just fine.

Just my opinions,
JAD

PS: what kind of cases do you think the ABTS is going to expect the new "six year" program residents to be learning in a Cardiac track? I suspect endovascular will a significant component... within a hybrid OR.

 

[pRotAgOnIsT]

JAD,

Didn't/don't mean to sound like an aNtOgOnIsT.

I have a question for you thoug regarding your statements on the anticipated wave of multimillion dollar endo suites being built for CT surgeons. When A TEVAR can be easily done in the OR with a C-arm in about an hour, why are multimillioni dollar endo suites necessary for CT surgeons? Are there other uses for these suites from a CT surgery standpoint?

I don't disagree with you that general surgeons do vascular surgery. My comments have all been about endovascular therapies. I too have read many, probably hundreds, of general surgery job offers and I have yet to see one that reads "bread and butter general surgery, some vascular, and some endovascular". Though perhaps I haven't been reading the same offers. Though as a general surgeon, I would not be comfortable doing anything other than aortofemoral runoffs, and possibly iliac angioplasty/stenting. I wonder if I would even be granted privileges for these. I wonder how the IR/cards/pure vascular types would view me doing even these procedures. Sure I could go and take a minifellowship for up to 10,000 dollars plus room and board, and probably feel pretty comfortable doing more, but I wonder how I would get the patient volume in private practice to develop and sustain my catheter skills. I don't see that referral pattern developing either. If I really wanted to be a vascular surgeon, I'd just do a fellowship.

I take it you're a CT fellow, or young attending, and I appreciate your optimism. I sincerely wish you the best in your career, and hope that you get everything out of it that you want. I'm not interested in either a vascular or a cardiothoracic career so I am not motivated to hype either field. I base my opinions on this matter on my albeit limited experience of being a general surgery trainee for the last few years so I realize my opinion may not be worth much.

Maybe some general surgeons in practice, vascular surgeons/fellows, or practicing CT surgeons are kicking around and could weigh in. I'd be interested to hear what they think.

 

[JackADeli]

...why are multimillioni dollar endo suites necessary for CT surgeons? Are there other uses for these suites from a CT surgery standpoint?

Sure I could go and take a minifellowship for up to 10,000 dollars plus room and board, ....I'm not interested in either a vascular or a cardiothoracic career so I am not motivated to hype either field. I base my opinions on this matter on my albeit limited experience of being a general surgery trainee for the last few years so I realize my opinion may not be worth much...

1. CV surgeons are using endo for percutaneous & trans-apical valve replacement in addition to thoracic Aorta
2. If vascular is doing AbdominalAA stenting in one room.... won't be available for CV
3. CV is starting to look into endovasc arch type procedures
4. Some mini-fellowships charge you while other PAY you a stipend
5. Things are changing rapidly in all fields, especially the minimally invassive components. So, yes things have changed in the last several years. I think over the last five years there have been persistent reports of the end of CV surgery as a career. Now,the ABTS has required two different tracks to board certification and stated the plan for a six year integrated training program straight out of medical school by year 2019. You are entitled to your opinion. I would say that coming from your perspective kind of not accurate to then speak to what ABTS leadership is or is not doing.

JAD

 

[ESU_MD]

If I recall- most of the groundwork for modern vascular surgery was created by the same men who developed heart surgery. Thus, most, if not all, old school CV surgeons are very comfortable doing routine vascular cases. In fact, alot of these guys were grandfathered and are boarded in vascular. These surgeons often fill a void in the hospital and do the routine vascular cases, especially in private practice settings.

I did read an opinion paper that specifically mentions trying to limit who does vascular procedures in a hospital and the person mentioned both the rogue general surgeon as well as the cardiac surgeon as "targets"

-General surgeon doing vascular on the side- a dying breed I agree.

However, I cant really think of a cardiac surgeon who isnt capable of handling the routine cases of AAA, CEA, fem-pop, dialysis access, etc.. You just have to know your limitations.

Cardiac surgery IS vascular surgery.

To this day, training programs still exists that are designed to produce true CV surgeons, although unfortunately, many individuals belittle the vascular part of the their training and seek out programs who do little vascular work. The joke will be on them though- alot of jobs require proficiency in vascular as well as cardiac. (guess what cases the new guy is gonna do!!_)

As far as endo skills- TEVAR is a great procedure, but there really arent enough to build a practice on and only do TEVAR. Although it doesnt take many cases to get proficient. I think the medtronics guys will give you a certificate after deploying like 5 (obviously this isnt the same as a local credential)
As mentioned earlier- they really arent technically challenging procedures at all. I dont really see a big turf war developing between CV and vascular surgeons. In fact, I've only seen collaboration, with both of these specialties "gathering the wagons" to box out the IR/IC guys. Any experienced vascular surgeon knows there is alot more to TEVAR than just landing the stent and they are happy to have a colleague involved who can assist with decision making as well as help with any complications that could arise above the diaphragm.