When Do Vascular Surgeons Need to Think Outside of the Box? 

A Keck Medicine of USC expert explains how vascular surgeons innovate to treat complicated cases.

Vascular surgeons, especially those who practice at advanced research hospitals, are often called on to come up with “out of the box” treatments for complex cases. 

“In vascular surgery, each patient’s case is often slightly different,” says Sukgu M. Han, MD, MS, a vascular and endovascular surgeon with the USC Cardiac and Vascular Institute, part of Keck Medicine of USC. Han is chief of vascular surgery and endovascular therapy and co-director of the USC George and Meryl Young Aortic Center. He discussed when vascular surgeons need to devise new strategies. 

Before we talk about less-common cases, can you share some examples of times when vascular surgeons can adhere to established guidelines and procedures? 

Han: One example is abdominal aortic aneurysm. Level 1 data from past studies has shown there is actually a size-related risk of aortic rupture, meaning that until the aneurysm gets to a certain size, particularly in men, the risk of rupture is so low that you don’t need repair right away. 

Another example is carotid stenosis, where the risk of carotid stenosis does roughly correlate with the risk of stroke. In asymptomatic patients with mild stenosis who haven’t had any stroke-like symptoms due to this plaque, the risks of carotid endarterectomy to clean out the plaque, or even trapping the plaque in its place using stents, which in itself can cause strokes procedurally, can be more concerning than the risk of a stroke. 

These are examples of instances when there are recommended thresholds of when to intervene.  

As a vascular surgeon, what you do is invasive by nature and carries certain inherent risks. So, the benefits of treatment have to justify the surgery, and this has a lot to do with the natural history of the disease process, the underlying diagnosis and what could happen if the condition were left untreated. 

Can you share some vascular surgery examples of times when a typical treatment might not work for a patient? 

Han: When a patient’s anatomy is such that it makes standard operation really difficult — for example, if the aortic aneurysm is very extensive, involving some of the major branch arteries supplying blood to critical organs — those patients don’t fit nicely within the confines of level 1 data. This is because in order to be included in those trials, patients have to meet certain anatomic criteria. So, inherently, applying the treatment modality to more complex patients involves more risk. 

These are the patients for whom we have to think about solutions that are outside of the box, when standard tools don’t exist. Sometimes you have to be creative and devise the tools yourself, or sometimes you have to modify existing tools. 

The other challenge lies in the fact that because the prevalence of these complex diseases is lower compared to standard disease processes, most centers do not have a lot of experience in doing these high-risk operations regularly. By contrast, Keck Medicine has consistently been a very high enroller of these complex cases and a leader in next-generation device trials. 

As a vascular surgeon, what do you appreciate about the opportunity to innovate new treatment solutions? 

Han: There are core principles of vascular surgery that we abide by, but the technology and research are moving all the time. And so along with that, the treatment options change.  

One of the reasons why most people, including myself, fall in love with the field of vascular surgery is the fact that we can actually drive some of these directions of future technology based on clinical needs. The pace of innovation is probably second to none, and we constantly have to come up with the best solutions for a patient, which can be slightly different than solutions for the last patient with the same diagnosis. 

How is technology helping vascular surgeons innovate new treatments?  

Han: Innovative technology is helpful for the most part. It can help expand the treatment options for patients who were previously considered too high-risk for conventional surgery. In that sense, it is a tremendous opportunity for physicians. 

There is a flip side, though: having multiple new tools at our disposal raises similar problems as having too much knowledge due to the explosion of the Internet. This access to technology can sometimes cut both ways where the vast availability of treatment options can dilute true expertise. For instance, the next generation of surgeons might not spend as much time training doing conventional surgery. So, there’s always a pendulum swing. But overall, I think more technology is a good thing. 

How do you guide patients through treatment that deviates from standard treatment? 

Han: You have to completely disclose the nature of the procedure that you’re doing and advise them, “This is not a standard procedure. Here are the treatment options at our centers as well as others around the country. These are the reasons why we think this procedure, which is outside of the standard, is actually beneficial for you.” Patients may not remember all of the technical details, but they value the transparency, and it enhances their trust in the surgeon.  

Topics

Jennifer Grebow

Jennifer Grebow is manager of editorial services at Keck Medicine of USC.

Share

FacebookPostLinkedIn