When did you perform your first angioplasty?

The first patient I treated with angioplasty was in 1974. It was done with a very early technology—an iliac angioplasty that was done with a caged balloon. The significant technological challenge at that time was how to keep a balloon from continuing to get bigger as you inflated it.

What first attracted you to interventional radiology and endovascular therapy?
In the early 1970s, the concept of image-guided therapy was in its infancy. The first CT scanners were being developed, the improved use of fluoroscopy was developing, and the Europeans were developing the concept of using imaging to guide needles and catheters. When I went into radiology, I was somewhat reluctant about leaving clinical medicine. Once I was in radiology, it seemed to me that it was a good way reintegrate clinical medicine back into imaging through developing image-guided therapy.

How has the practice of endovascular therapy evolved since that time?

What kinds of changes have you observed, and how has the relationship between physicians and industry changed? The field of endovascular therapy has matured significantly in the past 15 years. What started out as a field called angiography has now evolved to a much broader concept, fulfilling in many ways the great promise that was defined by Charles Dotter in 1964. He believed that this was really a type of surgery that was being done with different types of instruments. There have been dramatic changes in: (1) our ability to visualize, (2) the safety of the procedures, (3) their effectiveness, and (4) our ability to more broadly apply them. The great promise of endovascular therapy is just beginning to be fulfilled, in large part because of the participation of the multiple disciplines that use these techniques.

In terms of the relationship with industry, it has become clear that a field that is so technology dependent cannot advance itself without great support from industry. This has been an area of great partnership, in which industry has worked with physicians to identify clinical needs and has made appropriate investment to advance technology that allows us to improve patient care. If you look back 20 or 30 years, the relationship with industry was much more separate and also much less productive. I do not think endovascular therapy could have advanced without this significant partnership with industry.

How do you see the role of the interventional radiologist evolving in the future?

Interventional radiology involves endovascular therapy but it also involves a lot more; specifically, the general concept of image-guided therapy, even outside the circulatory system. This is an important area of practice for many interventional radiologists. I feel very strongly that interventional radiology needs to transition into a clinical discipline to continue to have relevance. Interventional radiologists need to develop the necessary skill sets and participate in clinical care and longitudinal care regardless of the disease process. This is true for areas of UFE and interventional oncology. This change has begun to occur, but it needs to happen to a much greater extent for interventional radiology to advance.

Will there soon be a need for a new discipline in vascular care? I believe we can all benefit from the development of a new discipline or development of a vascular specialist. One of the benefits of having three disciplines involved in vascular care is that it definitely serves to advance awareness among primary care physicians and other physicians about what had almost been an orphaned disease in terms of delay in diagnosis and misdiagnosis. Unfortunately, the energy expended on turf issues and conflicts takes away from the potential for further advancement. From a broader perspective, vascular therapy is a very comprehensive term, and there are people who bring multiple skills to the table. Some sort of merged training program that could accept participants from interventional radiology, interventional cardiology, or vascular surgery, all of whom are dedicated to endovascular therapy and endovascular care, would be a great step forward. Regretfully, I think medical societies today represent inherent barriers to this idea moving forward. There is a model for this type of program in nuclear medicine. It is possible to obtain Board certification in nuclear medicine from either an internal medicine, pathology, or radiology path. The leaders in our field should strongly consider a similar structure for endovascular therapy.

What are your thoughts on the current state of AAA therapy? What improvements have made the most significant impact? Despite some speedbumps that have occurred in the development of EVAR, it is definitely moving forward. I think we have learned a number of things. First, the outcomes can be technology dependent, and it is probably best to try to optimize a specific device to a specific patient's anatomy. We have not yet reached the point that one device fits all patients. Second, when you push the envelope of this technology, it is definitely going to affect outcomes in an adverse way. Sometimes it is necessary to take that risk, but it must be recognized.

In terms of future developments, we need to continue to develop technology that will be applicable to more patents. Currently, only a small cohort of patients (maybe 40-50%) are amenable to endovascular therapy. We also need to continue to miniaturize devices. I believe that the ultimate solution will be percutaneous in nature. We need to develop materials and designs that will improve durability.

What are your thoughts on the current state of CAS therapy?
What improvements have made the most significant impact?

CAS is both one of the most exciting advances in endovascular therapy and clearly one of the most contentious. I have some concerns about CAS, primarily directed at ensuring that physicians get appropriate levels of training to be able to perform CAS well. We have learned a lot about that in various clinical trials. I hope that physicians will be responsible in understanding the risks to patients and the risks to the advancement of CAS as a result of them not getting adequately trained. Overall, I am very excited about CAS. Clearly, it is a step forward for patients who are at high risk for surgery and I do believe that we must move forward with trials to define whether CAS is going to fit in the low-risk patient population.

Which issues regarding training and accreditation most need resolution?

Currently, one of the major issues is that training is specialty specific. Even the most recent training and credentialing guidelines produced by various medical societies are clearly specialty specific. We need to develop a common platform on which to credential so that regardless of your background, the patient can be assured of receiving care from an appropriately trained physician.

Now that CAS has been approved, one of the significant concerns that I have is that device training guidelines from the manufacturer will be misinterpreted as credentialing guidelines and will become the de facto credentialing guidelines. Hopefully, hospitals and responsible physicians will understand that credentialing is an entirely different process from device certification.

At many of the specialty meetings and conferences, live cases are being performed with increasing frequency. Are there any ethical concerns associated with these presentations? I am a very strong believer in the benefit of live case education. That being said, I have significant concerns about the increased use of live cases for teaching purposes. As one of the originators of using live cases for teaching purposes, I am convinced of their value as a teaching tool for operators who have certain baseline skill on which to take information learned and apply it. Unfortunately, I think many of us have witnessed live case presentations in which the primary educational objective has been lost. I think it is critically important that when patients are part of live case demonstrations, the principle focus should be on patient care. I believe that if live cases are to be performed, the physician should examine the ethical issues involved with it. I think very clear educational objectives for each case should be delineated. All of us vary in our ability to teach and do live cases, and unfortunately I see people get into a situation in which they feel compelled to do live cases. I think this, like performing different types of procedures, is a teaching exercise that requires its own skill and comfort level. Each operator should examine whether it is the right thing for them, their patient, and the teaching objective. I do believe that physicians should take a look at this, perhaps through the ACCME or other vehicles before other government agencies do.