The Mid-Century Vascular Surgeon

A Mid-Century Modern Chair

Mid Century Modern is a design philosophy from the mid twentieth century that seemed terribly dated and out of style while I was growing up but now seems to have come back as people dig around their parents and grandparents’ stuff. Television shows like Mad Men and Marvelous Mrs. Maisel are rotten with mid-century design. Yet it is an apt term for vascular surgeons of a certain generation like me who at about fifty years of age remember a time when vascular surgery was about big incisions and bypass grafts. We were trained in open vascular surgery and rode along with (or were drowned by) the tsunami of endovascular techniques that have come to dominate. Most of us learned to do them as well. Mid-century vascular surgeons straddle the divide between our mentors who, like me, specialized in vascular after completing general surgery training and the current trainees who have trained solely in vascular surgery. At one time it was fashionable to believe that we were fossils. But, like the coelacanth discovered after an eon’s absence, guidelines and recommendations are being made for open surgery which is supposed to be making a comeback. But it turns out, open surgery-capable vascular surgeons are, like the coelacanth, rare, and endangered. Unless we completely change the way we train people today, open vascular surgery will become extinct. At first glance, it does not look good.

The Dinosaur
My first ever encounter with a vascular surgeon was in 1989, as a lab tech in Boston the year after I graduated from college. It was at the West Roxbury VA Hospital, and like the vets, this one chain smoked in his office. Friendly enough, but a bit aloof, he rasped out well elocuted English in the same way soldiers did in old war movies like The Longest Day. Laconic and Robert Mitchum-like. He would have been among the first generations of vascular surgeons, contemporary to Jack Wylie, Michael DeBakey, and other luminaries. He couldn’t have cared less, I believe, as he performed fem-pop and aortobi-iliac and femoral bypasses and carotid endarterectomies with a furious incandescence that didn’t jibe with his reserved demeanor outside the OR. He was equally fierce to the residents when he had to scrub in to get them out of jam. But he was kind to the medical students and pre-meds like me. His type of surgeon is most definitely extinct, remembered only in old war stories like this.

What is it about my generation of surgeons? We remember things and balance the new against the old ways. We remember a time before work hours restrictions but are young enough to understand why it is not too healthy to work 120 hours a week. Yet we are also conflicted about the benefits we retained from that kind of training, now viewed with about as much approval as Sparta’s agoge system of child abuse and military training. I trained at the outset of laparoscopic surgery, so I did about 50 open cholecystectomies before learning how to do laparoscopic cholecystectomies. Most of my appendectomies were done open. As were my colectomies, gastrectomies, thyroidectomies, mastectomies, and yes, aortic surgeries, carotid endarterectomies, arteriovenous fistulae, and leg bypasses. And I did them.

We All Agreed…
This was the deal. You worked at 110%, fell exhausted and gave a little more, and you were rewarded. That meant being up all night on call, but after morning rounds, you could turn your pager off and operate all day. If you were learning, you had to be prepared by knowing the patient, the disease, the anatomy, and the operation. If you were teaching, you had to have the approval of the attending who would be somewhere nearby, and never happy if you grabbed them. If you were chief resident, you were basically junior staff and expected to run your service like a practice. The leash was longer for those who could, and short for those who could not. In the grade before mine, it was pyramidal, meaning there was attrition of those who could not progress. Like ringing the bell at Navy SEAL school in Coronado, people quit. Or were, rarely, fired. Being categorical was seen as a kind of entitlement by the disbelieving chiefs welcoming the new categorical interns. Dishonesty was the worst sin, but weakness, like showing fatigue or expressing a desire to have a life outside of work, was equally bad. And training was long. Four years of medical school, followed by five years of general surgery residency with mine extended by a year of research between third and fourth year, and then followed by a two-year vascular fellowship. By the time I was a full-fledged vascular surgeon, I had college friends who had actual homes and summer homes, children, divorces, and travels around the world. They had lived real adult lives. I started out on life at 35 where everyone else had done it at 21. But I had 1600 cases in my residency, of which over 300 were major vascular including 50 open aortic cases, and nearly 500 cases during my fellowship, adding another 100 aortic cases, most of them open, as it was the first years that EVAR was introduced. Nothing better in the world than to start a case with Ken Cherry quipping over your shoulder -“make me proud.” I finished my endovascular training apprenticed to Dan Clair during my first staff job at Columbia P&S -cue Dan intoning “you’re killing me” over the Cath Lab’s PA from the control desk on the weekends we had time in there.

There is no going back…
That represented one way of training a vascular surgeon. Even after graduating, I never stopped learning and perfecting my craft. The two years at Columbia gave me insight on how to run a practice completely alone -I was the lone vascular surgeon up at the Allen Pavilion on the northern tip of Manhattan next to Baker’s Field. It taught me the critical importance of availability and extracting useful information over my tiny flip phone. During my private practice years in Iowa, I learned the amazing productivity that can be attained when you work in collaboration and partnership with cardiologists and cardiac surgeons -something I do today here in the Heart and Vascular Institute. I also learned how to use vascular technologists and the lab as a force multiplier. And it was during the Iowa years that I underwent a period of endo-enthusiasm followed by a realism and I performed over a hundred aorto-bifemoral bypasses on middle aged patients with an average length of stay of 3 days, no deaths. When I plunged back into academia, taking a position at Cleveland Clinic, I was apprenticed again to Dan, but this time in understanding how to use the whole clinic as a tool for taking impossibly challenging patients through to an acceptable resolution. All of that started with those frantic days on call as an intern at St. Luke’s Hospital, drawing blood cultures, placing IV’s, babysitting traumas in the CT scanner, and putting chest tubes into the perforated. But there is no going back. It is most definitely probably illegal today to subject people to the intensity and duration of experience that I went through. And I wouldn’t trade that experience for all the treasure in the world (although I do regret not buying Apple, Dell, and Microsoft in 1994).

What a completely trained vascular surgeon can do
The hardest case that I have taken care of ever was at the Clinic a couple of years ago. The patient was a middle aged man who had ruptured an aortic aneurysm in another state some months prior and had undergone a repair complicated by a pancreatic injury along with some enterotomies resulting in a graft infection along with high output pancreatic and enteric fistulae from an open abdomen. He arrived cachectic, in septic shock and had a pseudoaneurysm from the distal anastomosis of a short tube graft. I immediately took him to the OR to place a stent graft across the pseudoaneurysm neck to prevent rupture and placed him on TPN to correct his cachexia. The abscesses and hematomata were drained percutaneously, and an effort was made to control the fistula with a heroic effort on the part of the ostomy team. He turned around and was able go to an LTAC on TPN and antibiotics. There he gained twenty pounds and returned flush and active. Stage two was three months later and done to replace the still infected grafts with cryopreserved homograft. I did this via a right retroperitoneal approach as the left side and abdomen were a mess from the inflammation. After I removed the grafts and sewed in the homograft, general surgery reorganized his bowel and discovered that he only had about 30cm of useable small bowel and would be on TPN for life. But he was alive and learning to walk again, and eventually came back 6 months later for follow-up and gave me a hug.

That case took all of my skill to solve, and I could not have done it without the whole hospital working in sync with me. When it comes my time, I wonder who would be able to do that for me?Who would manage my ruptured AAA properly and not have bowel and pancreatic injuries?

How to do a CABG according to Dr. Swistel
When I was an intern, I wanted to be a cardiac surgeon more than anything else, and got myself slotted for 6 months of cardiac during my second year. It was an unwanted rotation because of the 5am to 11pm hours, all nighters in the unit on call, and because the CT surgeons were notorious for not letting you do anything, except for Dan Swistel. Years before he had been one of us, a resident at St. Luke’s/Roosevelt and was Dr. George Green’s protege. He had a deal with us where he had you learn and master all the following steps in this order:
1. take vein
2. put in pacing wires and chest tubes
3. close chest
4. open chest
5. open the pericardium and set up the way he wanted
6. put the venous cannulas in
7. put the arterial cannulas and secondary lines in and go on bypass
8. decannulate and repair
9. dissect the aorta, set up and place the cross clamp
10. do the proximal anastomosis on the vein grafts
11. do the distal anastomosis on the vein grafts under the microscope which was the way he and Dr. Green did it.
12. dry up…really dry up and learn to come off pump
13. take mammary
14. book a ward service CABG and do it skin to skin

Through the history of St. Luke’s up to that point, most residents never got past taking vein. That was the great barrier, and most people really didn’t stick around after taking vein and closing the leg. They did not see the point of standing around and second or third assist. Those residents who were going to Cardiac did make it to taking the mammary, but only a handful by chief year. No one made it to 14. Dr. Swistel was always true to his word, even though some residents suspected this was all some bet that he had between himself and his brother who was not a cardiac surgeon -something about I can train a monkey to do this. To me, that last step, doing a CABG skin to skin, seemed like the final level of a very difficult computer game, like casting the One Ring into the volcano, like blowing up Agent Smith.

Every step on the ladder was something I immediately applied to my general surgery experience. On call and at home, I practiced. I practiced holding the instruments correctly and performing anastomoses on discarded grafts. I learned that every hard operation is made up of small technically feasible components, so I worked to make those moves natural and smooth. I progressed rapidly up the ladder and was by the end of my last cardiac rotation firmly at 13 on more than one occasion. Every other part of my skill set expanded during this time -central lines went smoothly, appendices and gall bladders were fished out efficiently, and fear shifted its focus to different things from what made me anxious as an intern. I learned the skill of keeping people alive through the night and making the call to take people back.

With some social engineering (ordering the cardiology fellows takeout Chinese) and vacation days traded, I got to that last step during my third year. If not a monkey, then at least Park. The act of learning and mastering each component skill lets you start and finish an operation. I don’t think Dr. Swistel was ever out to lunch while I was operating, but all those moments of letting me take the knife was crucial to my education and I am grateful to him and all my teachers, including my current partners and colleagues, as I approach PGY-25.   As surgical educators, we must recognize that surgery at the sharp end of the knife is a precision craft that has to be taught much as tennis is taught starting with grip, stance, swing. That golf is learned on a driving range with a bucket of balls.

The Mid-Century Vascular Surgeon
Like Mid-Century Modern Design furniture, surgeons in my cohort are sought after by hospitals and practices for being able to let a hospital do more. What do I mean? A urologist resecting a kidney with a renal vein tumor thrombus extending into the inferior vena cava needs to have someone expose, extract, and repair the vena cava. A gynecologist debulking retroperitoneal metastases needs to be able to call for help when part of the aorta needs to go with the tumor. Cardiac surgeons need to be able to place ECMO cannulas in imaginative locations and not lose extremities in the process. A thoracic surgeon resecting a Pancoast tumor needs a vascular surgeon to repair the subclavian artery and vein. An orthopedic surgeon resecting a spindle cell tumor from the thigh needs help reconstructing the femoral artery and vein. And so on. We are safety net, the fire brigade, the SEAL team, and unfortunately many hospitals understand only when their last fully trained, full service vascular surgeon retires.


Vascular surgeons are a keystone species in a hospital’s ecosystem. When wolves were reintroduced to Yellowstone, it was noticed that decades later the forests returned to their ancient glory, that wetlands flourished breeding fish and insects and small mammal species, and the secondary predators that feed on them, and many missing bird species returned. Vascular surgeons capable of operating on the whole body as well as intervening on the whole body are increasingly a missing element in a hospital. And many of us chose to go missing -into our private endovascular suites and vein centers because it often does not pay to go do a 5-hour bypass when you can do three femoral angioplasties for claudication in the same time. Reading 10 carotid ultrasounds is easier on the back and more renumerative than a carotid endarterectomy. And I am not judging -it is a rational choice that is framed by the way healthcare is reimbursed.

The solution starts in the US with a shift in reimbursement to recognize the time and effort required to perform open vascular surgery well and to reward the programs and surgeons who are consistently good. Training in open vascular surgery will be sought after much as everyone wanted to be a cardiac surgeon back in the 1970’s. Government and society mandates set the menu, but the economics determine what is served.

And finally, every year thousands of surgeon-years of experience is retiring with the very skills that are now sought after. Rather than lose this human capital to golf courses and beaches, we should be grabbing them at the door.  Like those mid-century chairs and tables, we have always been there somewhere, and its time to make some more.

At the Intersection of Art and Science

tube graft

I taught myself to draw during medical school when I couldn’t figure out the three dimensional relations of structures. I discovered that if you just draw the shading of an object, it pops out in three dimensions. Over the years, I took to carrying little notebooks to sketch out anatomy and proposed operations for patients through this medium. While I found this to be a handy tool that I used only occasionally, since moving to Abu Dhabi, where much of my communicating is done through an interpreter, my drawings carry a much greater weight as direct communication of my thoughts and intentions.


Drawing helps the patient and family understand the unseeable. It gives form to words that are often confused like blood vessel, graft, stent, artery, and vein.


What is informed consent when patient’s cannot describe their problems to their friends and relatives what the problem is and what is going to be done about it?


I usually draw with the pen in my shirt pocket and some copier paper, but sitting down and doing a proper sketch is soothing and very helpful for me as the surgeon to previsualize the goals that I have to reach during an operation to take the patient across the finish line. During meetings and conferences, I sketch into one of those fancy bound notebooks that I collect.

Funny thing is I was doodling during class as a kid, but it was spaceships, not aneurysms.

While pencil and markers do a fine job, the real magic is in using tablet based sketching software, using layers, to build serial images of the steps of an operation.


I am increasingly tempted to use these images as my operative note, but understanding that words are needeed for billing, I comply. Even so, I find it helpful to put these illustrations on my EMR notes, because it allows everyone to see and understand what I saw and what I did. I leave you with some of my illustrations with attached comments.

Long segment disease stents in their natural occluded state


Our best shot

The nutcracker
The fractal
Hybridized aorto-bi-iliac revascularization
Retrieving the unretrievable embedded filter
3 step treatment of a type II thoracoabdominal aortic aneurysm
Dysphagia lusoria, treated
Targets under the ulcer
I’m not sure this really works
An off pump CABG for a vascular surgeon
Phase 1

Phase 2

Innovating Our Way Out of Not Having Enough Vascular Surgeons

view out window
View out of my balcony, sometimes you need many pieces to assemble a beautiful whole

Innovating Our Way Out of Not Having Enough Vascular Surgeons

This year’s SVS meeting featured a sobering assessment about the vascular manpower deficit affecting North America at the E. Stanley Crawford Critical Issues Forum, moderated by Dr. Michel Makaroun, MD, president-elect of the SVS. 35-45% of practicing vascular surgeons plan on retiring in the next decade by conservative estimates. We are not attracting enough candidates for the training programs. The solutions, including decreasing the length of training, public relations campaigns, and incentivizing retention have had mixed results, but we have yet to see a sustainable rise in vascular surgeon numbers.

Burnout driven by lack of work-life balance, the advent of electronic medical records optimized for billing, the passing of the private practice era, and the constant need to adapt to new techniques, create a persistent downdraft on staffing. So as some hospital face the reality of having to contract services, little attention is given to delivering best care with the staffing that we have. Changing how we practice is the only viable solution.

There are an estimated 3000 active vascular surgeons in the US. Imagine if all the cheese needs of this country could only be met by 3000 artisanal cheesemakers who make cheeses one at a time and want to live in places with international airports, BMW dealerships, and major league sports teams, and must have 3-4 partners to share cheese call. If you are a rural hospital in dire need of vascular surgery services and your one vascular surgeon is retiring, you are probably SOL.

When I was training, vascular surgery was oft touted as a primary care specialty. And that is how many of us still practice, managing risk factors, monitoring mild disease, as well as planning and performing interventions and operations. As much as I enjoy that kind of interaction, the half hour to an hour visit for a head to toe cardiovascular survey and discussion, educating patients and families about pipes and pumps, is incredibly inefficient. A healthcare system, a hospital, facing a staffing shortfall, has to do everything possible keep that vascular surgeon in the OR during work hours.

What is the core function of a vascular surgeon? Making good decisions and executing plans well. Decisions require data. What is this data? We laud the history and physical examination, but this is a throwback to another era. If you look at the diagnosis of myocardial infarction, it is not standard practice for a cardiologist to come and get a history, examine the patient, and declare that the patient is having a heart attack based solely on history and physical examination. It is a triage nurse in the ED who draws labs and orders an EKG which is read by a machine. These data points will tell you if heart muscle is being damaged. A process is started which triggers a team to come and take care of this patient. The hospitals focused on this actually drill their cath lab teams like pit crews. A stopwatch starts with the goal of revascularization under an hour.

Not so with peripheral vascular disease. The ischemic foot might have only a few hours depending on its presentation before it is irretrievably lost, but no matter -they sit in the ED until a vascular surgeon comes to speak to the patient and family, examine them, and then order tests, admission, consults, and operating room -typically all by themselves. Getting these patients into the operating room is in many places hampered by the lack of dedicated OR staffing, radiology techs, anesthesiologists, space, equipment, and critical care capacity. During work hours, there are scheduled cases that have to be delayed or canceled for another time, which takes time to do. After hours, the patient may have too many comorbidities to handle safely with the available staff. The vascular surgeon may have to bargain and cajole, to align several factions whose attention is demanded by many equally important concerns. If you decide to hold a lavish dinner party of twenty important guests -reserving space, calling caterers, inviting guests, arranging transportation – on short notice, you might pull it off once, but if you do this regularly, you are a masochist of the first order.

In the heart attack model, the history and physical examination is relegated to a series of yes/no or how long questions, and positive responses trigger a series of coordinated actions of a system -a reflex. In the leg attack model, there is no such system. I have to blame the vascular surgeons for preserving the current model.  Vascular surgeons are organized as a guild. Guilds are protective of their monopolies on skills and markets and fiercely resist change. Most vascular surgeons are terrified by loss of control, and cling to the notion of being misunderstood and unappreciated saviors. We can do better.

The area that needs streamlining is at the point of referral. The majority of time of a vascular surgeon is spent working up normal blood vessels, varicose and spider veins, leg edema and pain, and mild and moderate arterial atherosclerosis. This work initially does not require a vascular surgeon but rather a focused set of policies and initial diagnostic studies that can be administered or ordered by any caregiver. Reducing the need for vascular surgeons at this point in vascular care will go a long way in extending the vascular work force at hand.


Point of Care Blood Flow Evaluation

Finding and declaring blood vessels to be normal is challenging and too often time consuming. Streamlining this will go a long way in freeing vascular surgeons to take care of disease.

The average caregiver is an inconsistent pulse taker. The palpable pulses are not always easy to find. Asking over the phone or as policy for someone to examine pedal pulses -the posterior tibial artery and dorsalis pedis artery pulses, is challenging. A positive is just as likely to be true or false as a negative. No cardiologist would ask a similarly detailed and technical question about an MI. In fact, they can’t ask, “Is there a pulse in the LAD?” Cardiologists make do with tests easy to obtain and interpret with certainty -the plasma troponin level and the EKG. The EKG is read by an algorithm so established and so tested, that it should stand as an example of early machine intelligence taking over a human job -but I digress.

What is our EKG? It is not the ABI -the ankle brachial index, because it is terrible at identifying disease, and is difficult to obtain reliably without practice. The closest thing to an EKG we have in terms of simplicity and accuracy is the pulse volume recording, the PVR (figure below). A FloLab machine, the machine used to obtain PVRs, will basically run itself once the cuffs are correctly applied on the leg, and the tracings are very easy to interpret. Unlike an EKG, there are no electrodes whose locations you must memorize. If the closest vascular surgeon is an hour away by ambulance, the transfer of a patient with flat waveforms and ischemic foot does not require a consultation on site. The patient would go to the vascular surgeon with no time wasted and no kidneys injured by CTA’s that too often fail to travel with the patient. Unlike an EKG which can be performed by many caregivers, a PVR requires both the equipment and a vascular technologist. A vascular technologist is not available 24-7 in most hospitals, and FloLab machines purchased for vascular labs are not meant to be dragged around the hospital.

PVR graphic.png

So let’s think out of the box about another box in every triage nurse’s cell, every ER and ICU bed, and on every hospital nursing floor. These are pulse oximeters with a digital tracing, and bonus points, some come with strip printers! Placing a pulse oximeter probe on the second toe and comparing to an erstwhile normal wave signal such as on an index finger can provide qualitative information about normality and disease. Normal waveforms and abnormal ones can be easily discerned. A flat line is another obvious finding when in comparison, a finger or an ear on the same patient has normal signals.

digital ppg foot.png

digital ppg hand.png

How much better would a vascular surgeon feel about a transfer call that has this information, “digital waveforms are flat in this patient with rest pain and a bruised toe.” How much better would a vascular surgeon feel about a call about a patient with “digital wave forms are normal in this patient with toe pain and a bruised toe. We got an x-ray and there was a fracture.” The communication can be quite detailed and refined. For example: “The patient had no pulses, we think. Digital wave forms were dampened but pulsatile in a patient with a bruised toe, we’ll send to vascular clinic in the morning.”

A study comparing pulse oximetry signals and ABI in type 2 Diabetes Mellitus found the following results (link).[i]

Method Sensitivity Specificity PPV NPV
Pulse oximetry 74.1% 95.7% 83.3% 92.7%
ABI 70.3% 87.1% 61.3% 91.0%

These data suggests pulse oximetry signal is equal to and somewhat better than ABI. Why is this important? Cost. This information is better than asking unsure people, “Is there a pulse?” A vascular technologist need not be on call 24/7. Extra FloLabs for ED, ICU, and floors need not be purchased. The pulse oximeter with waveform tracing is nearly ubiquitous wherever patient’s oxygenation needs to be assessed in most hospitals. While not perfect, it has great potential for serving as vascular surgery’s EKG machine for critical limb ischemia. Policies and algorithms can be built out in collaboration with Emergency Departments and nursing departments that can effectively determine if blood flow is normal or abnormal at point of care. Effective emergency responses to critical limb ischemia can be authored triggered by abnormal findings. Acute limb ischemia protocols based on time sensitive responses can be initiated. All of these can flow from referring entities being able to determine objectively normal or abnormal blood flow.


The vascular clinic is a sorting process where patients are determined to be normal or have mild, moderate, or severe disease. The vast majority of the time spent in clinic can be spent in triage by trained nurses and testing by technologists. Clear pathways and guidelines can dictate the ordering of vascular laboratory tests obviating the need for vascular consultation at this stage. Patients with normal blood vessels and vascular function are sent back to their physicians with the normal report. Patients with mild disease and moderate disease are sent to a physician with specialization in cardiovascular medicine for management of risk factors and periodic surveillance. At any point in the process, a vascular surgeon can be called to provide guidance and direct patients to different tests and consultations. The patients needing operations, based on correct indications and imaging are sent to a focused clinic where the surgeon and interventional team can review films, determine the urgency of indications balanced against risk, and plan and schedule procedures. Currently, vascular surgeons do all of this by themselves, as well as make hospital rounds, perform procedures, and interpret vascular laboratory studies, seeing one patient at a time.

In introductory computer sciences courses, search algorithms are taught to be brute force if you look at one item at a time for the thing you want, and to be efficient if you have presorted those items because every time you look, you can exclude part of the data set, ever shrinking the pool in which you search, making the search shorter and faster

The shortfalls in vascular surgeon numbers have as much to do with this dependence on the star chef cooking up one meal at a time, rather than a team working off recipes, with the chef directing the flow and occasionally jumping by the fire to make the most difficult of dishes. The first restaurant can seat three parties. The latter, easily ten times the number. Everyone gets fed.

Only asking how many vascular surgeons you need misses the big picture because there are many equally important questions. How many vascular technologists do you need? An accredited laboratory provides the critical diagnostics upon which decisions are made, and the surgeon should oversee but not be directly involved in the initial screening. Nurses trained to triage and order vascular laboratory tests and even perform the simpler ones is the second need. Third, is the cardiovascular medicine physician who manages those patients discovered to have mild to moderate disease, and depending on symptoms, refers severely symptomatic moderate disease and severe disease to a scheduling clinic. The scheduling clinic is composed of both interventionalists and vascular surgeons who plan interventions and operations.

Surgeons must be in the operating room to be effective. A well thought out and organized system, with interlocking teams, and well disseminated basic knowledge and awareness of vascular diseases reduces the need for a vascular surgeon to be present all the time in many places and ultimately increases the effectiveness of the vascular surgeons that are available by keeping them in the operating room. The system needs to be set up by the surgeon to allow clinic to be a setting mostly for consenting the patient for an operation or a discussion of treatment options.

Finally, vascular surgeons must be aligned with all the resources of the hospital including the considerable numbers of interventional cardiologists and radiologists, neurologists, and nephrologists. There is no reason someone should wait a month to get on the OR list for an iliac angioplasty and stent if an equally skilled and privileged cardiologist or radiologist has an opening the next day. The surgeon’s special talent should be open surgery and hybrid surgery -that which mixes open surgery and intervention in optimal measures which is not possible from a purely percutaneous approach. The key is frequent and easy communication between specialities and trust built by being in one shared cardiovascular institute.


There is a critical need of good operators. The acuity of disease and their solutions demand the continued presence and availability of open surgery. The fact is, many solutions are optimal in a hybrid fashion and for peripheral vascular disease, these options can only be offered via a vascular surgeon trained in both open surgery and peripheral interventions, or in a combined effort of open surgeon and interventionalist. And many disease categories can only be managed by open surgery.

The reality is that silos, economics, and practice patterns prevent this kind of combined effort. Market forces have pushed the training of vascular surgeons forcefully into the interventional realm at the cost of open surgical training. Some of the geographic maldisdribution of vascular surgeons has to do with younger vascular surgeons flocking to established practices where there are senior surgeons more comfortable in opening a belly or chest (or both). The trap they and hospital systems fall into is then allowing these new recruits to become the interventional specialist of that group, relegating the aging open surgeon to a narrow role, and then finding that the hospital has a problem when that surgeon announces retirement at 60. Every year, millennia of surgical experience retires to beaches and golf courses. The hospital systems should recognize this brain drain as a crisis and create work arounds that keep these skills going. The other opportunity lost is close coordination with interventional cardiologists, radiologists, and nephrologists who in many cases compete with vascular surgeons for the same patients but treat the patients based on their training and skill sets to the exclusion of potentially better operations offered by surgeons. This disjointed care creates both suboptimal outcomes for patients and high costs for hospital systems.

Commerce should never dictate the fate of a patient. A particular point is where competencies and privileging overlap, and guidelines recommend intervention over surgery as in the case of a TASC A or B iliac artery lesion. A patient should not be kept waiting weeks for a spot on a busy surgeon’s OR schedule when an open interventional cardiologist or radiologist slot is available for a iliac stent the next day. It should be a matter of practice that these cases are discussed and distributed, optimally in a shared indication clinic or rounds. Patients bumped off of a surgeon’s elective schedules for emergencies who could be cared for by an interventional partner without an added delay should be given that option. This kind of change requires a commitment to continual reorganization and optimization into a vascular institute.



The perfect vascular surgeon is a unicorn -well skilled, and experienced in open vascular surgery, but also versatile, innovative, and skillful in wielding a wire. I can name just a handful of unicorns. An apt analogy from the book Moneyball is the signing of superstars in baseball on the free agent market. The upshot of that book is that you can arbitrage for the valued metrics through signing several utility players with an aptitude for one thing or another which in sum equals or exceeds that superstar and get the final result -wins, in the same proportions as overspending on a superstar. Rather than searching for that unicorn, it is more important to set up the right system. Screening, testing, and management of mild vascular disease by a nurses and cardiovascular medicine physicians, while directing operations and interventions to vascular surgeons, cardiologists, and interventional radiologists should be the next step in the evolution of vascular care systems. There will never be enough vascular surgeons in the current system. The critical and rare competency is open vascular surgical skill. A surgeon who performs only interventions is not an “advanced minimally invasive practitioner” but rather someone equally privileged as an interventional cardiologist or radiologist, and therefore easily replaceable by an interventional cardiologist or radiologist specializing in peripheral vascular disease. A surgeon skilled in open vascular surgery is becoming rarer every year, but they are still out there, looking at brochures of real estate in sunny places. A team consisting of a cardiovascular medicine physician, many vascular  technologists, nurses specializing in vascular diseases, several interventionalists, and a vascular surgeon skilled in open vascular surgery working as a single unit, is far more easy to assemble than finding and recruiting a herd of unicorns.


[i] Kumar MS et al. J Assoc Physicians India. 2016;64(8): 38-43.