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Viewpoint: adaptation of vascular surgery in the interventional era Edward Choke, Robert Sayers Department of Cardiovascular Sciences, University of Leicester, Leicester, UK Correspondence to Dr Edward Choke; Department of Cardiovascular Sciences, University of Leicester, Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK; [email protected] Received 29 July 2014 Revised 5 November 2014 Accepted 8 November 2014 Published Online First 23 December 2014

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INTRODUCTION In the UK, vascular surgery and interventional radiology are both involved in the management of patients with vascular disease. Both have the required skills and proficiencies, with their own distinctive advantages in treating vascular patients in specific situations. Keeping pace with state-of-the-art practice is a basic prerequisite of any modern surgical specialty. The state of the art in vascular surgery is no longer open surgery; it is endovascular techniques. From the patients’ point of view, endovascular procedures have obvious advantages in achieving quicker recovery times with subsequent shorter hospital stays, improving clinical outcomes and reducing rates of infection. From healthcare institutions and commissioners’ point of view, the cost savings from shorter hospital stays and less morbidity are economically appealing. The high expense of imaging equipment, of building and staffing of dedicated hybrid theatres and of the endovascular devices themselves are potential obstacles. However, the combination of strong patient preference with top level evidencebased medicine from randomised controlled trials demonstrating comparable medium term efficacy will continue to drive the trend towards endovascular techniques. The interventional radiologists’ skill sets are dedicated to minimally invasive techniques. Vascular surgeons have been quick to recognise these benefits, and therefore, many have adopted interventional techniques into their skill sets. This encroachment by vascular surgeons into a territory customarily occupied by interventional radiologists needs to be addressed judiciously and delicately. The overall aim is to achieve a delicate balance of relationships to deliver the best possible care to vascular patients. There are obvious values in trying to resolve any ensuing conflicts and find means to flourish in situations where physicians collaborate effectively with each other. This article reviews the drivers for change in vascular surgery, the reasons for the development of the potential ‘territorial conflict’ in vascular medicine and proposes some possible solutions through restructuring of vascular care, training and improving communications, within the era of modern vascular surgery in the UK.

DRIVERS FOR CHANGE IN MODERN VASCULAR SURGERY Aortic mortality To cite: Choke E, Sayers R. Heart 2015;101:342–345. 342

One of the main drivers of change has been the historically poor clinical outcomes for abdominal aortic aneurysm (AAA) surgery. An NCEPOD report in 2005 titled “Abdominal aortic aneurysm: a

service in need of surgery?”1 revealed high mortality rates in the UK after AAA repair. This was followed by a Vascunet report in 2008, which showed that UK was an outlier with the worst death rates after elective AAA repair at 7.5%, double the average for the rest of Europe.

Quality improvement programmes (QIPs) The high aortic surgery mortality resulted in the initiation of the UK AAA QIP2 by the Vascular Society of Great Britain and Ireland (VSGBI) backed by funding from the Health Foundation. The programme was rolled out nationally with collaborations from British Society of Interventional Radiology and involved patients, surgeons, anaesthetists, radiologists, nurses and hospital managers. Through implementation of key action plans including remodelling of vascular services into higher volume centres, outcomes across the UK were improved such that in 2012, the overall death rate following aortic surgery was reported at 2.4%. The VSGBI has also produced a Provision of Vascular Services 20123 document that sets out the minimum requirements for service delivery by vascular units. A vascular unit should now have a minimum of six vascular surgeons and six vascular radiologists working together as a team on a one in six emergency rota. To achieve this, many units have reviewed their delivery of services and either amalgamated to form larger units or adopted a hub and spoke model where all arterial work is moved to a single site (the hub) with ongoing provision of outpatients, day case and other services (diabetic foot clinics) on the second site (the spoke).

Remodelling of services into higher volume centres Another key driver of change has been the realisation of a volume–outcome relationship in vascular surgery. This relationship has now been shown to apply to all index vascular operations where good outcomes are directly related to the number of cases performed by a vascular unit. Much work is currently ongoing in the remodelling of vascular services in the UK. In the 2013 National Vascular Registry Report on Surgical Outcomes,4 111 hospital trusts (458 surgeons) provided data on AAA repair and 114 trusts (429 surgeons) on carotid endarterectomy (CEA). According to the data, a median of six AAA repairs per year were performed by each surgeon (range of one to 237 AAA repairs per 5 years).5 This suggested that from 2008 to 2013, many vascular surgeons in the UK did not perform enough AAA repairs each year to meet the minimum standard of at least 10 AAA repairs/year for aortic repair as

Choke E, et al. Heart 2015;101:342–345. doi:10.1136/heartjnl-2014-306131

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Viewpoint defined by the National Health Service Standard Contract for Specialised Vascular Services in Adults (NHSSCSVS).6 Furthermore, 107 hospital trusts (92.2%) did not meet the NHSSCSVS targets of more than 60 AAA repairs and 50 CEAs per year and at least six vascular surgeons per unit.5 However, centres that met these targets were associated with better outcomes for both AAA repair and CEA, thereby supporting a policy of restructuring of vascular services in the UK in accordance with the main standards set by NHSSCSVS. The end result of this reconfiguration of vascular services means that, in the future, there will be fewer vascular units; but the remaining vascular units will be bigger with the emphasis on groups of consultants from vascular surgery, vascular radiology and other specialties (vascular anaesthesia, critical care medicine, cardiology and diabetology) working together as teams.

The National Vascular Registry The Kennedy enquiry into paediatric cardiac deaths in Bristol in 20017 emphasised the importance of national audit for surgical specialties. In vascular surgery, the National Vascular Registry had previously been a voluntary central audit for many years but has now become compulsory. It collects data on the index operations in vascular surgery (aortic aneurysm repair, CEA, lower limb bypass and amputation). Surgeon-specific rather than unit-specific outcomes for aortic and carotid surgery were first made available to the public in 2013 and this is likely to continue to occur each year with further expansion of the data to be made freely available to the public.

Endovascular surgery Another major driver of change was the endovascular revolution that has occurred in aortic aneurysm surgery. Endovascular aneurysm repair (EVAR) was first described in the mid-1990s. The technique involves deploying an endovascular stent graft inside the aneurysm and fixing it to suitable proximal and distal landing sites in the non-aneurysm arterial wall above and below the aneurysm sac. The stent graft is usually introduced via the femoral arteries and fixed to the arterial wall with hooks and barbs which are ballooned into place. EVAR has been evaluated by several randomised trials and has been shown to have lower mortality than open repair in the short-term to mid-term although the benefits may be lost beyond 8 years.8 Initial concerns about the need for secondary interventions have diminished as stent-graft design has improved and a policy of duplex ultrasound rather than core training (CT) follow-up has reduced the overall cost. As expertise and technology have developed, more challenging cases have been performed. Currently, short-necked aneurysms can be repaired using fenestrated grafts with holes to allow perfusion of renal and visceral vessels. More extensive aneurysms of the suprarenal segment have been repaired with branched grafts and thoracic aneurysms and dissections have been repaired with thoracic endografts.

Aneurysm screening There was a long-term aspiration in vascular surgery to introduce a national aortic aneurysm screening programme. Aortic aneurysm is a common cardiovascular disease and accounts for 4000 deaths per annum in England and Wales. Aneurysms grow slowly providing an opportunity to screen and intervene before rupture occurs. Modern duplex scanners are inexpensive and portable with a high sensitivity and specificity. In addition, several randomised trials have demonstrated the benefits of screening in men. The major barrier to screening was concerns about aortic mortality and so a Choke E, et al. Heart 2015;101:342–345. doi:10.1136/heartjnl-2014-306131

potential screening programme was a further driver for reconfiguration to reduce mortality. The combined effects of reconfiguration, the Vascular Society QIP and the introduction of EVAR have reduced aortic mortality and allowed the successful introduction of the National Health Service Abdominal Aortic Aneurysm Screening Programme in 2013.

SHRINKING VASCULAR SPECIALTY AND TECHNOLOGICAL ADVANCEMENT IN INTERVENTIONAL RADIOLOGY Specialisation is not a new phenomenon. New specialties develop from parent specialties due to the ever-growing body of knowledge and technological advancements in procedural skills. Vascular surgery has undergone such an evolution. In the UK, vascular surgery was traditionally a ‘subspecialty’ of general surgery. In this model, consultant surgeons in the UK practised vascular surgery in conjunction with general surgery. As the sophistication of vascular interventions increased, the exacting and highly challenging procedural skills required full time dedication to the specialty and the concept of the general surgeon who performed the occasional vascular surgery became less acceptable to patients and service commissioners. Furthermore, data then begun to emerge that UK specialist higher volume units which practised vascular surgery as their only specialty had better outcomes than smaller lower volume units that sporadically did these cases. The establishment of vascular surgery in the UK as a monospecialty in 2012 was, therefore, considered inevitable (and maybe even overdue) by many UK vascular surgeons who were initially trained as general surgeons but who practised only vascular surgery. Since its description in 1951, the Seldinger technique has undoubtedly improved the safety of transarterial procedures, and interventional radiologists have been instrumental in perfecting and refining the technique before any other specialties. Such procedural skills were traditionally not considered surgical skills, and surgeons were content with not incorporating these procedures into their surgical portfolio. They were, therefore, satisfied to refer their patients for peripheral angiograms and angioplasties to the interventional vascular radiologists. However, it became very clear that vascular surgery would become interventional-led. Endovascular advancement continued into management of AAAs and it soon became clear that EVAR would become first-choice treatment over traditional open AAA repair. Similarly, endovascular stenting was trialled for carotid diseases although its uptake as first-choice therapy was much less successful compared with EVAR. Vascular surgeons, therefore, started to recognise that they had to expand their procedural capabilities to include catheter skills or that they could potentially face being an unsustainable and outdated specialty. Unsurprisingly, vascular surgeons started to reclaim territories that were once willingly conceded. They were able to do this because vascular surgeons get the first referrals for patients with vascular diseases that potentially needed procedural interventions. The vascular surgeons then decide on the best management for patients, and they almost always are the decision makers as to whether a patient should be referred to an interventional radiologist. This situation is in reverse to that seen with coronary artery disease, where cardiologists are the gatekeepers and referrals to cardiac surgeons are made only if less invasive therapy was unsuccessful or deemed inappropriate by the cardiologists. One could argue that in vascular diseases, the first referral should intuitively be made to the vascular radiologists as they are the less invasive therapists. If the vascular radiologists feel that the patient is not suitable for interventional therapy, they may then refer the patient to the more invasive 343

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Viewpoint vascular surgeons. This is, however, not the referral pattern in the UK because vascular radiologists in the majority of units do not have admitting rights and as they do not have clinics, they remain a ‘doctor’s doctor’ at the present time. In polar opposites of cardiac surgeons, the referral pattern has meant that vascular surgeons were, therefore, were more equipped to evolve and embrace the changes necessary to become modern vascular specialists. Vascular surgeons realised that to remain a viable specialty, they must stop acting merely as the middleperson between primary care doctors and interventional radiologists. This necessitated not referring patients outright to vascular radiologists but vascular surgeons remained involved in the procedural aspects of vascular disease management. EVARs were naturally suited for combined surgeon and radiologist input as most early EVARs necessitated groin cut downs to be performed by surgeons. By remaining closely involved in EVARs meant that vascular surgeons were able to develop their catheter skills required to independently perform EVARs. The situation for peripheral angiograms and angioplasties are, however, different to EVARs as the surgeon’s input is not necessary from the beginning, and therefore the uptake of skills in peripheral work has been slower and fragmented. Vascular surgeons trained in peripheral work either had to undertake a specific fellowship in that field or they relied on the goodwill of their vascular radiology colleagues to train them. There is no doubt in the minds of vascular surgeons that vascular diseases in the future will be dominated by interventional procedures as first-line therapy, where only those who fail or cannot undergo interventional treatment will be considered for surgery. The discipline of vascular surgery was, therefore, keen to rebrand itself as reflected by the change in name from ‘Vascular Surgical Society of Great Britain and Ireland’ to ‘Vascular Society of Great Britain and Ireland’ back in 2004. Training has also changed and the first annual intakes of 20 ‘pure’ vascular trainees were selected in a national competition in 2013. The new curriculum will integrate traditional vascular surgical skills with formal training in interventional vascular radiology skills, with the aim of training future vascular surgeons or arguably, more appropriately termed ‘vascular specialists’. It is becoming more commonplace for vascular patients to present as emergencies; therefore, vascular trainees and consultants of the future must be prepared for substantial on-call workload which will include emergency endovascular work. This new curriculum is in contrast to current UK vascular surgeons, who received training in general surgery, with subsequent specialisation in vascular surgery in their final 2 years, frequently supplemented by an additional year of vascular fellowship training.

COMPETITION FROM CARDIOLOGISTS Patients with ‘vascular surgical diseases’, such as cerebrovascular disease and peripheral arterial diseases (PADs), are also likely to have coronary artery disease. These patients are, therefore, also likely to have been assessed by cardiologists at some point in time. Although rarely encountered in the UK, this is another potential area for ‘territorial conflicts’ and it is a situation seen in healthcare systems in other Western countries. Cardiologists who feel that their technical skills and knowledge with coronary angioplasties are transferrable to peripheral vascular interventions may believe they are also in the best position to provide endovascular treatment for PAD. In counterargument, very few interventional cardiologists have undergone accredited training in PAD management. 344

SOLUTIONS TO TERRITORIAL CONFLICTS Service restructuring and rebranding Co-operation between vascular surgeons and vascular radiologists are imperative if working relationships among the multidisciplinary teams are to be preserved, while delivering more efficient and higher quality patient care. Traditionally, vascular surgery and interventional radiology comprise completely separate financial units, even though they work together to diagnose and treat a wide range of vascular disorders. Intuitively, it would seem beneficial for vascular surgery and interventional radiology departments to combine resources and share expenses to form a single business unit. In departments where this has occurred, such as the Department of Vascular Surgery and Interventional Radiology at the University of Rochester Medical Centre,9 benefits were seen in terms of improved efficacy in practice management and cutback in expenses, elimination of economic pressures from clinical decision making and expansion of the educational experiences of vascular trainees. For reorganisation of departments in the hospitals to be successfully implemented, co-operation between staff from various levels are necessary, and these include physicians and funding bodies, hospital administrators, managers and department heads. The restructuring and subsequent rebranding of a new department of vascular medicine that comprise specialist physicians capable of delivering care across the spectrum of medical management, state-of-the-art diagnostic tests, endovascular techniques and open surgery is not a new concept. A similar concept has also evolved from changing working patterns between rheumatology and orthopaedic surgery, neurology and neurosurgery and respiratory medicine and thoracic surgery.

Improving communications Multidisciplinary Team Meetings (MDTs) have been universally adopted with great success by many hospitals to address the numerous requirements faced in complex healthcare environments. When used effectively within the setting of vascular medicine, MDTs can effectively break down the barriers, leading to improved communication among physicians. By discussing challenging, successful or unsuccessful cases in timetabled weekly or biweekly ‘case conferences’, physicians are able to combine their knowledge and unique skill sets to discussions, frequently resulting in the best consensus decisions on patient care. With regards to turf issues, conflicts are more likely to be avoided and instead collaboration can be developed and strengthened.

New training curriculum A finishing general surgical trainee in current times, with no experience with endovascular techniques, should not practise vascular surgery in the modern era. It has become clear that a new training programme in vascular medicine was needed in parallel with advancements in interventional techniques for vascular patients. This culminated in development of a completely new curriculum for pure vascular trainees in 2013,10 which was jointly agreed with the VSGBI, British Society of Interventional Radiology and The Royal College of Radiologists. By clearly agreeing on the required interventional skill sets of the future modern vascular surgeon, conflicts between surgeon and radiologists on what is traditionally the domain of interventional radiology are less likely to exist. In the new curriculum, vascular trainees will be required to achieve a minimum level of competencies in interventional procedures. After medical school all trainees in the UK enter into a mandatory 2-year Foundation Programme. Surgical trainees then enter into a further 2 years Choke E, et al. Heart 2015;101:342–345. doi:10.1136/heartjnl-2014-306131

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Viewpoint of CT in general surgery followed by competitive selection into 6 years of specialty training in vascular surgery. Within the new curriculum there is an agreement that the vascular surgeon trainees would receive formal training from the interventional radiology team. At the authors’ unit, this situation works well due to mutual respect and collaboration between the vascular surgeons and vascular radiologists. Interventional trainees are welcomed into vascular surgery theatres if they wish to develop their surgical skills such as groin cut downs for EVARs, and surgical trainees are allocated dedicated training slots in the interventional suites. Between the various colleges, it has also been agreed that units that are unable to provide interventional training to vascular trainees could lose their privileges as a training unit.

HOW CAN INTERVENTIONAL RADIOLOGISTS COMPETE IF VASCULAR SURGEONS ADOPT A NON-COLLABORATIVE APPROACH? The majority of specialist vascular units in the UK demonstrate a good working relationship between the vascular surgeons and the interventional radiologists, where the workload is shared in a mutually acceptable manner. Whether this will continue indefinitely into the future is debateable and there is a possibility that any pre-existing departmental loyalties and relationships might eventually be forgotten. The reality is that newer generations of vascular surgeons who are fully trained in both surgical and endovascular techniques may be less likely to involve their interventional radiology colleagues. If this was to occur, the lion market share of vascular services in the future will likely be monopolised by modern vascular surgeons who are fully trained in endovascular techniques and procedures. So how can existing interventional radiologists protect themselves from this situation? The vital factor lies in the pattern of referrals. Interventional radiologists struggle with one paramount issue and this is their relatively low profile and lesser brand recognition to the public and the referrers. Efforts could be made to change the current referral pattern from the referring community to vascular surgeons. For this to occur, interventionalists will need to provide comprehensive care to their patients. Elective referrals could be reviewed first by the interventional radiologist as a preprocedural consultation to decide whether the procedures requested by the vascular surgeons are suitable. To encourage direct recognition from the referring community, interventional radiologists should communicate directly with the primary care doctor about the treatment plans and outcomes. But for this to happen, it is imperative that interventional radiologists complement their technical skills with aptitude in the clinical setting, ranging from assessing patients from the point of first referral to making the final decisions on the most appropriate management plans.

Choke E, et al. Heart 2015;101:342–345. doi:10.1136/heartjnl-2014-306131

CONCLUSION Vascular surgery is a rapidly changing specialty and territorial conflicts are an inevitable reality in the 21st century vascular medicine. Advancement in technology has played a big role, compounded by the power of self-interest, which includes the justifiable acquisition of new skills to adapt to changes in modern medicine and to make a living. Territorial conflicts will continue to occur. Specialists possess a specialised skill set, which by definition is limited and, therefore, vulnerable to modernisation of medicine. In the interest of best patient care, it is critical not to let such conflicts distract physicians from their expected roles and responsibilities to their patients. It is important to recognise that the future of vascular (and endovascular) medicine is not the birth right of any one group or specialty in particular. Restructuring of vascular services to help resolve and abate any potential conflict will require a tremendous effort and dedication from the hospital managers and hospital medical staff. In the end, however, patients will be the ones who will benefit from the restructuring. Contributors EC and RS have both made significant contributions to the writing of the viewpoint article, drafting of the work and revising of the manuscript including intellectual content and approval of final version of the manuscript. The named authors agree to be accountable for all aspects of the work in ensuring that any queries with regard to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Competing interests None. Patient consent Obtained. Provenance and peer review Commissioned; internally peer reviewed.

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Viewpoint: adaptation of vascular surgery in the interventional era Edward Choke and Robert Sayers Heart 2015 101: 342-345 originally published online December 23, 2014

doi: 10.1136/heartjnl-2014-306131 Updated information and services can be found at:

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