Outside the OR
A vascular surgeon provides an opinion on how the OR environment may hinder the transition from surgery to image-guided therapy.
Endovascular procedural capabilities are of crucial importance in surgeons’ growing struggle to retain preeminence in the treatment of vascular disease. In our ranks, yesterday’s naysayers have mostly either evolved or passed on. Vascular surgeons continue to face formidable challenges, however. Although conceptually clear and seemingly simple, transitioning from conventional operative intervention to catheter-based approaches is far from straightforward.
THE IMPORTANCE OF HOW AND WHERE
For surgeons, the interventional journey is often a long, meandering, and bumpy road. Worse yet, there are opportunities for exercising poor judgment and making errors at every turn. The struggle relates to essentially every aspect of interventional therapy—from gaining access to catheter skills training, to locating appropriate pathways for implementation and credentialing, to defining proctoring needs and means, and so on.
Imaging and the workshop stand out as critical components. As applied to endovascular procedures, the term image-guided defines with accuracy the ‘how and where’ for interventional practice. Quality imaging and the right environment are absolutely paramount, as are sterility and proper lighting for surgery. No surgeon would feel comfortable operating in semidarkness or consent to working with dirty instruments. Intriguingly, if not regrettably, catheter-based procedures are at times undertaken in similarly suboptimal conditions. It has saddened me to observe that such misadventures tend to take place in operating rooms.
Most beginning endovascular surgeons look upon the OR as their interventional workshop of choice. These physicians’ reasons are self-evident, and relate primarily to issues of access, control, and familiarity. I must question, however, the wisdom of using the OR for such activities in light of several key observations.
Why the OR is Suboptimal
Imaging quality is of paramount importance. Mobile C-arms cannot compete with fixed state-of-the-art angiography or cath lab systems. The OR environment is obviously a surgical area, with limited and/or difficult access for visitors and others. Due to the need for sterility, the size of anesthesia equipment, surgery scheduling pressures, and the hourly cost of the OR, the space lacks user-friendliness and is not cost-efficient for diagnostic angiography.
Naturally, the background and training of OR personnel are strictly surgical. An endovascular support team, when available, would typically comprise two or three nurses and techs. These staff members hold the key to a surgeon’s ability to perform interventional procedures in the OR. He or she would be unable to carry out such procedures during off-hours and when there are no-shows due to sickness or vacation when the rest of the staff may be unable or unwilling to provide support.
Finally, availability of endovascular tools and products is problematic and is related to issues of inventory and location. ORs simply do not stock the necessary materials.
Advantages of the Interventional Environment
On the other hand, any interventional or catheterization imaging environment (including angiography suites, peripheral vascular labs, and the like), offers obvious advantages. Superior imaging equipment is readily available, for example, and an interventional staff is always present. Combine these factors with an adequate inventory of endovascular tools and a more user-friendly (ie, less strictly-sterile) environment, and it is clear why cath labs and angio suites are superior locations for performing endovascular procedures.
THE NEED FOR STERILITY AND RESCUE
Those defending the choice of the OR as the proper environment for surgeons’ endovascular practice may argue that a surgical setting is ideal because of sterility and the ability to convert to open surgery for rescue. Let’s examine these positions briefly.
In my opinion, sterility is a non-issue. With the exception of stent-graft procedures, which are and will likely continue to be done in the OR, catheter-based interventions are always performed percutaneously. Implantable devices are never exposed to the environment, as they are completely covered until released within the lumen of the target vessel.
The surgical rescue argument is even weaker. Although complications occasionally occur, when the physician is equipped with proper skills and experience, the need for surgical conversion should be (and is) essentially zero. The management of complications does not require a physician to practice in the OR.
OR proponents may maintain that inadequate visualization is no longer an issue because of the availability of new generation C-arm systems that provide excellent imaging. This is partially true as C-arms continue to improve. It takes only the personal experience of doing procedures in a ‘real’ interventional lab, however, for a physician to realize, once and for all, that there is no comparison.
The recent development of fixed-system state-of-the-art imaging suites may allow interventional-environment imaging capabilities to be duplicated in the OR. Whether or not it is wise to make an investment of that magnitude in such location within a hospital is a discussion for another article.
STEPPING OUT OF THE OR
Surgeons can reinvent themselves as interventional specialists, but it undeniably requires a total embrace, dedication, and sufficient ongoing experience. Those who only want to learn certain endovascular skills to do few or only some procedures will remain extremely limited in their abilities. Although there is nothing wrong with starting out performing interventional procedures in the OR (it may be the only possible way for many physicians to begin), aspiring interventionalists must clearly understand that the OR is not and will never be a truly interventional environment.
The policy of “let them do it in the OR and stay there,” as espoused by some competing specialists, may be intended to keep surgeons in an inferior and noncompetitive situation (interventionally speaking). Vascular surgeons who wish to become true endovascular specialists should take steps conducive to reach two fundamental goals. First, they must gain the skills and experience that are necessary to independently perform catheter-based procedures of all types, in all vascular territories. Second, such budding specialists must find a way to gain access to the best imaging suites in the hospitals where they work. Full training and credentialing are not geography-specific—surgeons need not feel confined to the OR, especially when doing non-operative procedures.
Frank J. Criado, MD, is Director of the Center for Vascular Intervention and Chief of the Division of Vascular Surgery at Union Memorial Hospital/MedStar Health in Baltimore. Dr. Criado may be reached at (410) 235-6565; firstname.lastname@example.org.