Let's evolve!

Ladies and gentlemen, members, colleagues! What an incredible year it has been. Certainly, being the President of Eastern Vascular Society (EVS) was a lot more work and time commitment than what I expected…despite multiple warnings by the past presidents to the contrary. But in the end, it was time very well spent. It has truly been an honor to serve as your president this past year. Thank you all for the wonderful opportunity and the personal growth it has afforded me. I would like to thank the entire EVS Executive Council (EC) and all the voluntary committee members for their tireless devotion in helping to get the society to the next level of excellence. This is time that is given (usually after workhours) that is unrelated to income. Thank you all for your incredible contributions! You all have personally made what EVS is currently today—the most relevant regional vascular society of the most populous area of the United States! I am pleased to report that we have had a spectacular year of growth with an unprecedented number of new members this year. The secretary of the society BK Lal and I signed a record 93 new EVS member certificates just prior to the meeting…. expanding our total membership to over 800! We are also being recognized by our industry partners as being the most significant non-national society for vascular specialists as reflected by our record ever rising financial support. To that end, I am pleased to report that our society is in great financial shape for years to come and will be able to continue to fund clinical and basic research in all areas of vascular disease. In addition, we will continue to offer generous travel scholarships for advanced care practitioners, allied health members, and trainees. I would like to take this opportunity to thank my colleagues at Maimonides Health (Alex Shiferson, Mahmoud Almadani, Richard Pu, Louisa Gambino, Susan Beale, and Olga Meyerzon) who without question filled in and did a huge chunk of the clinical work while I was tied up with EVS duties. I would also like to deeply thank my devoted fiancé, Colleen Lewis, who has been at my side coaching and encouraging me throughout the year, and my two daughters, Hannah and Mina, for their love and understanding throughout my career. I am still sincerely sorry that I attended only two parent-teacher conferences! By the way, for all the young parents out there, do not follow my footsteps in this category. It is an area of much regret for me. Finally, a special thank you to my mother (a retired Brooklyn Veterans Administration Medical Center nurse anesthetist) who inspired me to pursue medicine. Although she actually wanted me to specialize in plastic surgery because in her days, most vascular patients did not do well. She asked me when I was in surgical training, “why would you want to pursue vascular surgery when most aneurysm patients did so poorly!” Food for thought at that time for sure! Okay! As I was writing my speech last night…. after the gala…and after I made sure that I was up to date on my daughters’ doggie (Ziggy and Brie) activities on Instagram, I finally realized that I truly have a unique opportunity to basically say whatever I want and the Journal of Vascular Surgery (JVS) will publish it! Took all the pressure off really. From my perspective, I felt that the last thing that JVS and the EVS members wanted to hear at this address was a flowery dissertation on some vague topic. Believe me, as a philosophy major in college, I can fill this talk with endless ornate brilliance. But I will spare you all of that today. Instead, I will try to paint a picture of my vision of where we should all be in the care of vascular patients in 2022. At least from my vision last night! Our rich heritage in vascular surgery should be very important to everyone in this room. However, as I have learned through 27 years of practice, thinking forward and using all of our energy to “evolve” and to look into the future is the best way to ensure that our wonderful specialty of vascular surgery thrives going into the next decade and beyond. Therefore, I have decided to focus my address today on how our unique specialty can continue to “evolve” and be on the forefront of true lifesaving breakthroughs. I apologize in advance, but I hate to reach into the dark recesses of my blurry days in college but since I have a captive and possibly receptive audience, I will indulge! I was not telling the entire truth when I said I wasn’t going to fill you all with BS but…. I am going to start my address with a quote from Friedrich Nietzsche (my favorite philosopher) that will focus the essence of what I will propose to you today:“The surest way to corrupt a youth is to instruct him to hold in higher esteem those who think alike than those who think differently.”1Nietzsche F.W. The Dawn, 1881. Great Ideas of Western Man 1963, oil on canvas.Smithsonian Am Art Mus. 1984; 124: 249Google Scholar One of the real strengths of EVS is that we have the largest number and the most diverse group of trainees (the majority of all vascular training programs in the country come from our eastern seaboard region). Hence, I felt it would be befitting to direct my Presidential Address to the younger (and possibly the greatest) generation of vascular surgeons. I love the Nietzsche quote because it has in a basic form, reaching back to the pre-Nazi era in Germany, the concept of inclusiveness. Unfortunately, deranged individuals like Adolf Hitler distorted Nietzsche, who gave birth to the “Übermensch” or the superman concept, beyond recognition. However, as with many great ideas, this was taken out of context by many. He actually introduced the very concept that diversity was actually good for humanity. And that to “march in line” will ultimately destroy man and to “march to the beat of a different drummer” will benefit not only the individual but also all of humanity. There are countless examples of this concept outside of medicine and within medicine. The most vivid example today is the company Apple. I played golf last year with an Apple Human Resources Director who worked at the New York City headquarters. He told me that the hiring process at Apple actually preferentially selects those who have very different views from the Apple ecosystem. Someone from Samsung for example would be a prime catch for Apple! The rich diversity in the personnel is what leads to their continued success and daily evolution. That is precisely why they are so successful! That very concept is what we all need to embrace today as a modern vascular society. The best example of “outside thinking” in vascular was the incredible endovascular aneurysm repair (EVAR) evolution.2Parodi J.C. Marin M.L. Veith F.J. Transfemoral, endovascular stented graft repair of an abdominal aortic aneurysm.Arch Surg. 1995; 130: 549-552Crossref PubMed Scopus (65) Google Scholar However, I actually mean “revolution.” We took a hallowed index surgical operation (which by the way was the very operation that drove me to enter the field AND the operation that my mother used as an example to discourage me from entering the field when very few patients did well in most institutions). We, as the pioneering specialty, turned it into a true minimally invasive procedure that can probably be performed as an outpatient. With excellent long-term results more than 20 years later. No, it is not a failed experiment as some previous recent editorials in JVS have suggested.3Shanzer A. Endovascular infrarenal aortic aneurysm repair: perhaps we’ve gone about it all wrong.J Vasc Surg. 2022; 76: 352-353Abstract Full Text Full Text PDF Scopus (0) Google Scholar It transformed our specialty overnight to the highest levels with excellent outcomes, which cannot be compared at any level with open abdominal aortic aneurysm repair, again in most institutions. I was the general surgery chief resident at Rochester when Tim Chuter was the vascular fellow. As some of you may know, he developed the early versions of what now is the Cook Zenith EVAR device.4Greenberg R.K. Chuter T.A. Cambria R.P. Sternbergh W.C. Fearnot N.E. Zenith abdominal aortic aneurysm endovascular graft.J Vasc Surg. 2008; 48: 1-9Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar I believe he still collects the patent royalties from that device to this day. For all you young rising stars out there! Interestingly, the vascular chief at our institution initially ridiculed him at that time as being outright “crazy”! I recall sitting down with the director at that time and being preached how truly stupid it was to treat a “disease of expanding radial force with a device with constant expanding radial force.” Exact quote. What would have happened if Tim Chuter did not forge on and ignored his critics? He was essentially not allowed to perform the early EVAR animal studies at the main university hospital at Rochester. Because he was thought to be crazy. He did all of his early studies at a local community hospital (Rochester General Hospital [RGH]) that had the insight to allow him to continue his work! I was fortunate enough to participate in some of the early bovine EVAR studies with him at RGH. Just think about that. To all the young surgeons out there! Be a Tim Chuter. Don’t be a follower! Evolution and “revolution” in the vascular field take many forms but will to speak to four major areas, which I believe will allow us to beautifully evolve into the next era of excellence.1.Understanding the disease process and the limitations of what we can do as physicians2.Embracing new technology but not be blinded by false prophets3.Escape from the ethical black hole4.Embrace diversity to achieve success Let us again take a dive into the history of vascular surgery. Because if you do not know the history, then ultimate progress will be impeded simply by repeating old mistakes. Over and over again. It has been an amazing ride since the inception of the specialty back in the late 1970s. Yes, that is true, ladies and gentlemen, students and residents; we are still a relatively new specialty. I was fortunate enough to train with some early giants in the field like Jim DeWeese at Rochester (one of the founding fathers who authored the vascular surgery specialty charter; who was himself a cardiac surgeon). I gained some significant insight while on his service on why this specialty was created and the initial need for such physicians outside of cardiac surgery. He told me that vascular surgery was simply a necessity due to the complexities in the care of these patients (and this was before endovascular therapies) and that cardiac surgeons at that time simply did not have the bandwidth to manage the broad range of vascular diseases in an excellent manner. That was it. The other James DeWeese quote that I will never forget was that “vascular and cardiac surgeons do not cure anything.” We help patients by damage control. This concept is true to this day. Make no mistake, the real goal of surgical and endovascular therapies in 2022 is to slow further progression and decrease symptoms but not truly cure the vascular disease process. Therefore, let us evolve and not overestimate our abilities by offering solutions that overtreat our patients. We are fortunate today to have one of the true masters of open aortic surgery here today, Dr Ken Cherry. Through his teaching and those who preceded him in my training such as Ken Ouriel, I have developed a minimally invasive (in the truest term) method of taking care of complex aortic patients. He taught me that less is better. Faster is better. For the patient. Less dissection, minimal to no overtreatment will result in a better patient outcome. When I started my first job in Pittsburgh, I noted that both the senior surgeons there Michel Makaroun and Marshall Webster also practiced in a similar fashion. Less is better! I learned during training and during my early faculty years that this very concept is true. Similar to “nothing good happens in NYC after midnight,” it holds true for vascular operations and procedures. Nothing good happens if you spend 4 hours on a carotid endarterectomy! I still follow his principles especially related to the endovascular arena. There are too many examples of overtreatment in modern vascular surgery. A clear example is in the area of aortic treatment. As we embark on the exciting era of thoracoabdominal aortic endografting, we need to take special care that we are not overtreating these patients. Roy Greenberg, who also trained at Rochester during the time I was there. A brilliant pioneer by any means, but he had introduced one faulty concept that we should all take a second look at.5Callaghan A.O. Greenberg R.K. Eagleton M.J. Bena J. Mastracci T.A. Type Ia endoleaks after fenestrated and branched endografts may lead to component instability and increased aortic mortality.J Vasc Surg. 2015; 61: 908-914Abstract Full Text Full Text PDF Scopus (45) Google Scholar “Treat to the healthy aorta” is a popular motto these days but a very dangerous concept in essence because it by definition overtreats patients. Do we really need to place stents into healthy visceral vessels on these patients? Will the patient benefit from the “endovascular protection” in the long term? I challenge all of you to question that approach. Especially the younger generations! We must evaluate and constantly re-evaluate everything, even from giants like DeWeese and Greenberg. Consider Jim DeWeese’s original perspective on vascular diseases! Are we really helping patients by covering their entire thoracoabdominal aorta? Or performing interventions on marginally diseased femoropopliteal disease? I think not. Not for the patient. The next generation of vascular surgeons need to figure this out. Always remember that we are preventing our patients from suffering “too much” from their illness, but we are not cancer surgeons. Recall that we cure nothing. That role, we have to defer to our basic science vascular researchers who are searching for the Holy Grail and “cure” for vascular pathologies. Let us evolve and not be fooled by our success. Treat the patient, not the pathology. Vascular surgery has been in the forefront of medical and technological advances since the formation of the specialty. Nobody loves toys more than vascular surgeons. Well, maybe with the exception of cardiologists! From the very beginning, vascular surgeons questioned everything and strived to improve our techniques and approaches. A classic example that always stands out in my mind was Bob Leather (who was born in Brooklyn but ventured into the wilds of Albany), who questioned the need for using the bypass vein in the reverse position. He believed that the “to and fro flow” was extremely important for bypass patency and the size mismatch of the reverse vein grafts was intolerable. That kind of talk was heresy back in those times. Hence was born the “in situ” and nonreversed vein in situ bypass.6Leather R.P. Shah D.W. Karmody A.M. Infrapopliteal arterial bypass for limb salvage: increased patency and utilization of the saphenous vein used “in situ”.Surgery. 1981; 90: 1000-1008PubMed Google Scholar He questioned and evolved in a quintessential fashion. A new approach. New technology (needed to develop techniques and equipment, namely the valvulotome to perform the in situ bypass). An amazing example of being an iconoclast! From the very beginning, vascular surgery had a clear and rich history of evolving and embracing new technologies in our field. There are countless examples in the endovascular era with multitudes of devices that I would not have dreamed of when I was a vascular fellow. However, in current times, it becomes more important than ever to question everything. A dizzying number of devices become available to us through the 510(k) process. For those of you who are not familiar with the 510(k) Food and Drug Administration (FDA) approval process, it is a defined route for FDA approval when a device company is allowed to sell their devices based on the fact that their device “looks and performs” like a similar device already on the market based on the opinions of a few people in the FDA.7Zuckerman D. Brown P. Aditi D. Lack of publicly available scientific evidence on the safety and effectiveness of implanted medical devices.JAMA Intern Med. 2014; 174: 1781-1787Crossref PubMed Scopus (46) Google Scholar In a nutshell. I urge the younger generation of vascular surgeons to be critical of these new toys. These new devices must be scrutinized and evaluated thoroughly in active practice. Sometimes at the expense of unknowing patients. “False prophets” who blindly advocate these new devices without meaningful data must be challenged to produce meaningful data for what they preach (and they are all over the place at major meetings). It is up to the new generation of vascular specialists to be critical of these new toys before regular use. As we have the ex-editor-in-chief of JVS (and a dear friend and mentor from Mayo Clinic) in the audience today, I will try to dampen my call to question the literature. To all the readers of vascular literature out there, please continue to question everything! Just because a study was published in a high-quality journal does not mean it is true! That is why I make all of my trainees dive into clinical research to find out for themselves. It is key to having a sound and ethical practice after training. To all the esteemed investigators out there, also question the validity of every clinical study that you are about to put out there in the vast web! When an article is published in 2022, it becomes available to everyone in the world almost instantaneously! The days of exclusive society journals are over. We have a far greater responsibility now. Our own patients are reading the very articles that you all published last month! I recall vividly my first month in Peter Gloviczki’s lab as a vascular fellow. During the first month of my research year, he strongly chastised me for misleading a research concept in a grant proposal. He taught me that we had a primary responsibility to the patient outcome and that clinical research should be of the highest ethical order. Thank you Peter for instilling that concept so “heavily” into my being! During my training at Mayo, we even had to withdraw a paper from JVS because of inaccurate data. A very painful thing to do, but the right thing to do. Evolution in the ethics of research and clinical practice remains one of the most challenging areas for us. The complexities of the modern financial incentive plans should not drive us to perform procedures and operations that have minimal or no effect on the patient outcome. In fact, some therapies may harm patients. Let us not just do clinical research to “pad” our CVs. Publishing in the medical literature has significant responsibilities. Let us take these responsibilities seriously and only publish what will truly help patients! So let us evolve for the benefit of our specialty and for our patients. In both research and patient care. This generation of vascular surgeons have endured unprecedented ups and downs. The COVID pandemic, a major war in Europe, the massive stock and housing market roller coaster ride and the crazy politics and socioeconomic controversies that is 2022! I remember very clearly that the great Jim DeWeese believed in 1989 (not that long ago) that women should not go into vascular surgery because of the time commitment and rigorous training that is required in becoming a vascular surgeon. Yes, he was an incredible pioneer, but he had 1989 society beliefs. The very essence of evolution is to question everything! A female senior resident during my training questioned the great Dr DeWeese and fought to become a vascular surgeon. She succeeded! She defied the norm and eventually completed vascular training after transferring to another institution. Should Jim DeWeese be canceled for his views in 1989? Of course not. Should the founding fathers of our country be canceled because of what they did or did not do in the 1700s? We are looking at human evolution and should cherish the past to celebrate what we have now. Vascular surgery as a field can be viewed as a microcosm of the world controversies. If we are to evolve and grow to the next level, we must evolve and embrace inclusiveness and diversity. As Apple has. The last few years of EVS certainly have been filled with multiple controversies. As our esteemed past president Manny Mehta kept repeating during his EVS presidency, the EC and the president have a fiduciary responsibility to the members. This is your society, not mine or the EVS EC. The role of the EC and the President is to make sure we are leading in the direction that the members are comfortable with. To make EVS more inclusive, we proposed to the members expanding full membership status to allied health and advanced clinical practitioners. Not just vascular surgeons and physicians. The nurse practitioners and physician assistants are just as important as the physician faculty in our group in that they treat patients and teach our residents and fellows. They are just as invested in the field of vascular diseases as the surgeons and other interventionalists. Our founding members deliberately removed the word “surgery” from the name of our society because they too wanted to be inclusive. We proposed this inclusive concept to a membership vote and the majority clearly desired inclusivity. Yes, let us integrate all those who take care of vascular patients and allow them the full rights and privileges as physicians in EVS. We will change the bylaws as the direct result of this membership poll. Another recent example was when other medical societies placed socioeconomic statements on behalf of the members without their consent. To express the personal views of the EVS EC without membership consent goes directly against the very concept of leadership. Again, we polled the members, and the majority felt that a medical society (like EVS) should not get involved with politics or social issues. So we did not. It is a prime example of growth and positive evolution in our society. Finally, my last call for continued evolution and inclusivity is to embrace our fellow colleagues in the care of vascular patients. Vascular surgeons do not own vascular disease. We actually cannot ever reach that goal if it is a goal at all. There are blood vessels throughout the body. My vision is that vascular surgeons should be the gatekeepers (or the leaders of treatment). If a physician has dedicated his or her career to vascular diseases and can perform a proper procedure or operation, he or she should be able to do it. Bring them into the Vascular Quality Initiative database. Include them in our local and national conferences. Maintain them to the highest standards that we all follow. Board certification should not be an exclusive concept. It was not meant to keep out the physicians who are outside the specialty but to certify those who have taken extra training. But, as you all know, it is clearly not an indicator of excellence in patient care or ethical care. That, ladies and gentlemen, has to be regulated within. I know this is an unpopular view by many who continue to battle cardiologists, cardiac surgeons, and so on. But evolving means to think outside the box. I have known and witnessed some excellent cardiologists and interventional radiologists who can treat vascular disease just as well as any board-certified vascular surgeon. And I have also witnessed some of the most unethical and haphazard practices from board-certified vascular surgeons who have finished reputable training programs. This should not be a war. The patients are caught in the middle. After all, we learned most of what we know about endovascular therapies from the very specialties we currently attest as being our rivals. We are in essence the intruders. We actually ventured into their endovascular arena. Let us all work together. We have a lot to learn from each other. As the most diversified specialty (with respect to the types of vascular diseases we treat), we should be the leaders of vascular management. There is no point in battling the cardiologists and cardiac surgeons. Let us evolve and continue to learn from them. And vice versa! Exclusivity of societies is a dinosaur concept. Medical societies should be inclusive and never a status symbol like it was for many elite societies for many years. One of the leading academic vascular surgeons that I have had the pleasure to work with when I was in Pittsburgh was rejected by the Society for Vascular Surgery for whatever reasons for several years! That’s just simply wrong if he had the qualifications (which he did) and a dedicated vascular practice. Now the Society for Vascular Surgery is much more inclusive… as is EVS. That also means that the old academic guard of a dozen or so physicians who traditionally controlled most medical societies should not be able to exert profound influences on a medical society without consensus opinion. This is progress and more importantly evolution of a glorious medical specialty with a bright future. Again, I wish to express that it has been a true pleasure to be your president for the last year. I was humbled by the support of the membership and the EC. I learned that a medical society is more than just a way to have a meeting. EVS has evolved to be a true home for our members, with all the resources for taking care of your patients and to make sure we are all delivering state-of-the-art care to our vascular patients. After all, that is the primary goal. To take the best care of our patients in an ethical, effective manner. Let us continue to evolve to achieve this.