REFLECTIONS: FORTY YEARS OF VASCULAR CARE

Transcription

1 REFLECTIONS: FORTY YEARS OF VASCULAR CARE

2 REFLECTIONS: FORTY YEARS OF VASCULAR CARE

3 CEA AAA

4 CEA AAA

5 REDDY WHITEHOUSE ZELENOCK ZITO CEA AAA

6 EVAR CEA CAS AAA

7 VASCULAR SURGERY AS A SPECIALTY NON-INVASIVE TESTING CLINICAL OUTCOMES

8 TRAINING AMERICAN BOARD OF SURGERY AMERICAN BOARD OF THORACIC SURGERY INADEQUATE TRAINING

9 PROPOSED SET OF TRAINING STANDARDS ABS ABTS not prepared to proceed turf issue JAMES DEWEESE, MD

10 COMMITTEE FOR VASCULAR SURGERY Unofficial standards Voluntarily offered to programs Program Evaluation and Endorsement Committee JACK WYLIE, MD ABS / ABTS endorse similar standards

11 ABS -> Certificate Special Qualifications in General Vascular Surgery #1 First examination (1983) Outcomes Contributions

12 SPECIALIZATION 1984 American Board of Medical Specialists approves separate training American Board of Surgery - > 44 major reconstructions for GS residents

13 SPECIALIZATION Ongoing battle characterized by pettiness:

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16 SPECIALIZATION 2006: ABS established a Primary Certificate Training independent of general surgery General surgery -> 2-3 yr VS fellowship 5 yr integrated vascular surgery residency

17 SPECIALIZATION 2006: ABS established a Primary Certificate Training independent of general surgery General surgery -> 2-3 yr VS fellowship 5 yr integrated vascular surgery residency

18 NON-INVASIVE VASCULAR TESTING 1842

19 NON-INVASIVE VASCULAR TESTING Shigeo Satomura, MD 1842 Study of flow patterns in peripheral arteries by ultrasonics J Acoust Science Jpn, 1959

20 NON-INVASIVE VASCULAR TESTING Shigeo Satomura, MD 1842 Gene Strandness, MD Application of a transcutaneous Doppler flowmeter in evaluation of occlusive arterial disease Surg Gynecol and Obstet. 1966

21 NON-INVASIVE VASCULAR TESTING Shigeo Satomura, MD 1842 Gene Strandness, MD Application of a transcutaneous Doppler flowmeter in evaluation of occlusive arterial disease Surg Gynecol and Obstet. 1966

22 NON-INVASIVE VASCULAR TESTING Supraorbital Doppler Pulsed Doppler Angiogram 1842

23 NON-INVASIVE VASCULAR TESTING 1842

24 NON-INVASIVE VASCULAR TESTING Duplex imaging equipment commercially available 1842

25 Duplex Imaging EVOLUTION High resolution B mode imaging 3D image reconstruction Real-time detailed flow assessments

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27 CLINICAL OUTCOMES CAROTID DISEASE ANEURYSMS PERIPHERAL ARTERIAL DISEASE

28 CAROTID DISEASE CEA

29 CAROTID DISEASE JOINT STUDY OF EXTRACRANIAL ARTERIAL OCCLUSION CEA

30 CAROTID DISEASE COMMUNITY RESULTS CEA JOINT STUDY

31 CAROTID DISEASE COMBINED STROKE/MORTALITY 21% COMMUNITY RESULTS CEA JOINT STUDY

32 CAROTID DISEASE RANDOMIZED ASA TRIAL CEA JOINT STUDY COMMUNITY RESULTS

33 CAROTID DISEASE RANDOMIZED ASA TRIAL CEA JOINT STUDY COMMUNITY RESULTS RANDOMIZED TRIALS

34 CAROTID DISEASE RANDOMIZED ASA TRIAL CEA JOINT STUDY COMMUNITY RESULTS NASCET ACAS

35 CAROTID DISEASE RANDOMIZED ASA TRIAL CEA JOINT STUDY COMMUNITY RESULTS NASCET ACAS

36 CAROTID DISEASE CEA JOINT STUDY COMMUNITY RESULTS RANDOMIZED ASA TRIAL NASCET ACAS STENT APPROVED

37 CAROTID DISEASE CEA JOINT STUDY COMMUNITY RESULTS RANDOMIZED ASA TRIAL NASCET ACAS STENT APPROVED

38 CAROTID DISEASE CEA JOINT STUDY COMMUNITY RESULTS RANDOMIZED ASA TRIAL NASCET ACAS STENT APPROVED CREST TRIAL

39 CAROTID DISEASE RANDOMIZED ASA TRIAL STENT APPROVED CREST TRIAL CEA JOINT STUDY COMMUNITY RESULTS NASCET ACAS CREST 2

40 ABDOMINAL AORTIC ANEURYSMS

41 ABDOMINAL AORTIC ANEURYSMS Charles Dubost

42 Ancure Endograft: AAA Repair Lawsuits: Guidant Corporation and Endovascular Technologies Endovascular Technologies Inc., a subsidiary of Guidant Corporation have been fined nearly 100 million dollars for covering up defective stents that allegedly caused 12 patient deaths. The government charges alleged the company lied to the FDA by reporting only 172 malfunctions, while the company had recorded 2,628 malfunctions, which included reports Charles of Dubost 12 deaths and 57 revision surgeries to remove the stent. The company instead claimed the problems were fixed after it was voluntarily recalled for 5 months in March According to the US attorney: "Because of the company's conduct, thousands of patients underwent surgeries without knowing the risks they faced," he termed the companies actions "criminal." Additional charges may be brought by the Justice Department against executives of the company.

43 ABDOMINAL AORTIC ANEURYSMS Charles Dubost

44 ABDOMINAL AORTIC ANEURYSMS Improved peri-operative care Improved prostheses Evolution of imaging PE -> U/S -> CT -> CTA Risk stratification Reduction in mortality

45 ABDOMINAL AORTIC ANEURYSMS Charles Dubost

46 ABDOMINAL AORTIC ANEURYSMS Charles Dubost

47 ABDOMINAL AORTIC ANEURYSMS Charles Dubost

48 ABDOMINAL AORTIC ANEURYSMS Charles Dubost

49 ABDOMINAL AORTIC ANEURYSMS Charles Dubost

50 ABDOMINAL AORTIC ANEURYSMS

51 ABDOMINAL AORTIC ANEURYSMS Charles Dubost Who will be competent to repair AAA s using open technique in the future?

52 PERIPHERAL ARTERIAL DISEASE

53 PERIPHERAL ARTERIAL DISEASE First vein bypass

54 PERIPHERAL ARTERIAL DISEASE First vein bypass Resection of aortic bifurcation

55 PERIPHERAL ARTERIAL DISEASE First vein bypass Resection of aortic bifurcation Goretex introduced

56 PERIPHERAL ARTERIAL DISEASE First vein bypass Resection of aortic bifurcation Goretex introduced In-situ bypass

57 PERIPHERAL ARTERIAL DISEASE First vein bypass Resection of aortic bifurcation Goretex introduced In-situ bypass Endoscopic vein harvest

58 PERIPHERAL ARTERIAL DISEASE First vein bypass Resection of aortic bifurcation Goretex introduced In-situ bypass Endoscopic vein harvest Improved instruments, suture, etc

59 PERIPHERAL ARTERIAL DISEASE Charles Dotter SFA angioplasty

60 PERIPHERAL ARTERIAL DISEASE Charles Dotter SFA angioplasty Balloon angioplasty Andreas Gruentzig

61 PERIPHERAL ARTERIAL DISEASE Charles Dotter SFA angioplasty Balloon angioplasty

62 PERIPHERAL ARTERIAL DISEASE Balloon angioplasty

63 PERIPHERAL ARTERIAL DISEASE Balloon angioplasty

64 Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication Published Online: January 28, 2015; Published March, In the last decade, vascular specialists have readily adopted EVT as an attractive alternative to open bypass surgery for infrainguinal occlusive disease. PTA and stenting are the most commonly used EVTs for focal and intermediate-length stenosis.however, the development of other techniques and technologies, such as subintimal angioplasty, devices for crossing and re-entering long-segment total occlusions, stent grafts, and mechanical and laser atherectomy, have made it possible to successfully treat even advanced disease, leading some vascular specialists to advocate an endovascular-first approach for patients undergoing lower extremity revascularization. In most cases, endovascular procedures are well tolerated with minimal complications, require short hospital stays, and result in rapid recovery.

65 VASCULAR SURGERY o Remarkable maturation over the last 40 years o Dramatic benefits to patients o Significant challenges in the new world o o o Choosing wisely New methodologies with population health benefit analyses Thoughtful application of technology

66 VASCULAR SURGERY BILL FRY CHRIS ZARINS JIM STANLEY JIMMY YAO JOHN BERGAN

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