The Evolution of Vascular Surgery
Endovascular Today interviews Giorgio M. Biasi, MD, President of the ISVS, who discusses the worldwide mission of the society and the state of vascular surgery.
Endovascular Today: What is the current focus of the International Society for Vascular Surgery (ISVS)?
Dr. Biasi: The ISVS was founded in 2003 by a worldwide group of distinguished vascular surgeons because of the need to have an international organization committed to the recognition and promotion of vascular surgery as a defined specialty separate and distinct from general and cardiothoracic surgery. In addition, vascular surgeons have a real inclination and liking for endoluminal procedures for the treatment of vascular diseases. Some of these surgeons were first in line to adopt, perform, support, and divulge these procedures since the beginning of the fascinating new endoluminal world.
However, not all members of the vascular surgery community accepted these procedures with the same spirit. Some looked at this new venture not as an attractive opportunity in the best interest of their patients that could enrich their therapeutic vascular options, but rather as an inconvenient intruder or a mere "nothing" that was destined to rapidly disappear. Some accepted it with enthusiasm, others ignored it, and still others appeared to be driven to despair.
The original focus of the ISVS was, therefore, to provide univocal ways of conduct among vascular surgeons by creating one voice while engaging vascular surgeons worldwide to explore what is new and on the endovascular horizon and recognizing that vascular surgery continues to evolve.
Other accomplished objectives include organizing sessions and meetings for the membership. Examples include the 2nd European International Vascular and Endovascular Course (IVEC)/ISVS Joint Congress to be held in Milan, Italy (October 9–11), which will include a well-rounded scientific meeting, and sessions at other global scientific meetings, such as the VEITHsymposium in New York and the X Pan American Congress on Vascular and Endovascular Surgery in Rio de Janeiro, Brazil (October 28–November 1). Other educational events are currently being organized that include training vascular surgeons interested in endoluminal procedures, as well as nonvascular surgeons who might benefit from being tutored in open accesses.
The ISVS-affiliated centers of training fellowship programs were established 2 years ago and have received much attention from young fellows worldwide. These programs run for a period of 3 to 6 months or up to 1 year. Affiliated teaching institutions include Hospital Clinic, University of Barcelona (Barcelona, Spain) under the direction of Dr. Vincent Riambau; The Cleveland Clinic (Cleveland, OH) under the direction of Dr. Daniel Claire; AZ Saint-Blasius under the direction of Marc Bosiers, MD (Dendermonde, Belgium); and The University of Milan-Bicocca (Milan, Italy) under my direction. To date, we continue to receive an enormous amount of e-mails from young fellows of every continent interested in applying to these fellowship training programs.
Although our peer-reviewed journal, Vascular, is still a young publication, it continues to grow, the result of the submission of good papers and industry support.
Endovascular Today: Have the society's goals changed at all since its inception?
Dr. Biasi: The society's goals have not changed but rather they have evolved. For example, we have recently established a Women's Committee, chaired by Dr. Allison Halliday, of the United Kingdom. The committee is working on several new initiatives that will be announced and launched in October at the IVEC/ISVS Joint Congress in Milan. Finally, our international government relations committee is busy reaching out to other groups and world associations to establish ways to improve vascular care to the global public.
Endovascular Today: What steps have been taken to make vascular surgery a recognized specialty, distinct from general surgery, worldwide?
Dr. Biasi: I must reiterate that the ISVS's overall mission is to ensure that vascular surgery is recognized as a separate and distinct specialty.
Vascular surgery continues to evolve. Although vascular surgery is recognized as an independent specialty in some countries, for example, in Italy since the 1960s, other countries, such as the US, have not recognized it as a separate specialty.
The ISVS is currently identifying the status quo worldwide and will provide a nation-by-nation survey. We are ready to stand by any of our colleagues who are struggling for independence and facing barriers that are preventing vascular surgery from moving forward in their country. We are prepared to write letters to local governments, as well as national and regional societies, to explore ways to develop independence. Our door is open to every local, regional, and national society in need of our support.
Endovascular Today: What are some of the barriers to the ISVS's goals?
Dr. Biasi: The opposition of some general surgeons and the conservatism of some vascular surgeons in various countries create barriers to our goals.
Endovascular Today: Has the progress been different in the US versus other parts of the world?
Dr. Biasi: It is surprisingly so. For example, in the US, vascular surgery is not recognized as a separate and distinct specialty, yet many pioneers in vascular surgery are from the US. It is strange and somewhat difficult to interpret the reasons why there has not been a strong enough united movement—as in many other countries—toward independence from the general surgery governing structure. Vascular surgeons should have their own residency review committees, and who better than vascular surgeons to fully oversee the training and educational paradigms? There is no question that this will improve the delivery of vascular care to the American public.
Endovascular Today: You have discussed the emergence of a new type of vascular physician—the interventional vascular specialist. How will this entity differ from current vascular surgeons, interventional radiologists, or interventional cardiologists?
Dr. Biasi: Endovascular techniques were introduced in the 1970s to treat vascular lesions having difficult access sites and a high risk of mortality. In the 1980s and especially during the last 10 years, endovascular procedures have become practically the treatment of preference for almost all arterial diseases, both obstructive and aneurysmal, in the various arterial territories. In the 1990s, the introduction of an endoprosthesis with a stent completely revolutionized the treatment of vascular diseases, which until then, were treated with traditional surgery.
With the rapid, progressive increase in the number of procedures performed (approximately 100,000 in the year 2000 alone), the question of which specialist was most qualified to treat these cases became inevitable. Four specialties appeared to be eligible: vascular surgery, cardiology, radiology, and neuroradiology. More recently, other specialists, such as cardiac surgeons or vascular medicine physicians, have shown interest in this peculiar field of medical practice in rapid evolution, with the intention of dedicating at least part of their professional activity to it.
The vascular surgeon has good experience on the ward, in the operating theater, in both elective and emergency surgery, is familiar with arterial plaques and lesions, has an excellent concept of three-dimensional anatomy, and is aware of the importance of sterility.
The interventional cardiologist has equally good clinical experience on the ward but less surgical experience and less familiarity with plaques; but on the other hand, the interventional cardiologist has wider experience in coronary angioplasties than the vascular surgeon. Some vascular surgeons and interventional cardiologists have little practical knowledge on the use of radiological apparatus and imaging.
Interventional radiologists and interventional neuroradiologists are those who have the most experience in navigating and maneuvering guidewires and catheters in the vascular territories, but compared to interventional cardiologists and especially vascular surgeons, they sometimes have little experience in elective surgery, in emergency situations, and in patient follow-up. Their patient referral is at times scarce.
A situation has come about in which, in the interest of the patient, it would be preferable, in order to maintain the gold standard, that at least two or more of the aforementioned specialists be present and consulted in each center where endovascular procedures are performed. This situation may not always be possible and could cause conflict among colleagues of an endovascular team because it is quite clear that only one person at a time can be considered ultimately responsible for each procedure.
More recently, as a result of the tremendously rapid evolution of technical skills and professional acquisitions and development of new devices, the large majority of vascular procedures can be performed either endoluminally or through hybrid (endovascular and open) approaches.
It is frequently reported that a procedure is performed by an interventional cardiologist or radiologist with the support of a vascular surgeon, whose contribution is often required just for ancillary procedures, or it is performed by a vascular surgeon who does not have a background of adequate training in maneuvering catheters or in imaging skill formation and has difficult or insufficient access to imaging equipment.
We are witnessing a transitional situation. The problems that we are now facing did not exist in the past and will not exist in the future.
Endovascular Today: Why should vascular surgeons join the ISVS?
Dr. Biasi: National and regional societies cannot internationalize themselves by trying to attract overseas members. The main goal and concern of national societies is to focus on their own national rather than international vascular surgery issues; this must remain their primary concern. It must be emphasized that our mission is to try to make vascular surgery a specialty worldwide, which is essential to our survival as a specialty. Moreover, we also want to raise standards and offer members an opportunity to be involved in training programs to learn access techniques that they cannot be taught at home. This will particularly help members in developing countries. Finally, we also hope in the future to send council members to developing countries to assist them in their programs. Vascular surgery is threatened worldwide, and unless it is coordinated properly in an international manner with access to training in particular, and reaches specialty status, it may not survive in the long term. I cannot emphasize enough that every vascular surgeon who shares our views and opinions should join the ISVS today. Our Web site is www.isvs.com. I am personally available to answer any questions, as is Pauline Mayer, Executive Director.
Giorgio M. Biasi, MD, is President of the ISVS; Professor of Vascular Surgery, University of Milano-Bicocca, in Milano, Italy; and Chief of the Unit of Vascular Surgery, San Gerardo University Hospital in Monza, Italy. Dr. Biasi may be reached at +39 039 367021; email@example.com.