Russell H. Samson, MD

In this month’s Vascular Specialist, there are two letters to the editor that seem to imply a division in the SVS membership. The letters indirectly suggest that the SVS comprises two camps, on the one hand, academics, and on the other, community-based physicians. Further, although the majority of the membership comprises primarily of nonacademic surgeons, the leadership is, and will remain, predominantly composed of University-employed physicians. Implicit also is that there may not be a common agenda.

However, many questions come to mind: Are we truly a house divided? If so, how did this come about? Do community and academic surgeons indeed have different concerns that split us into camps? If so, how can we come together because the aphorism “United we stand, divided we fall” will have critical implications for the future of our specialty.

Dennis Gable writes that “the SVS is often (and historically) thought of as a society reserved for academic surgeons” because it is regarded solely as a vehicle to arrange a national academic meeting (the VAM). However, he counters that incorrect assessment by describing many fundamentally important roles that the SVS plays in the daily lives of practicing vascular surgeons. He encourages members to go online (at www.vascularweb.org) and see for themselves all that the SVS is doing for vascular surgery, vascular surgeons and their patients. The Society’s strong advocacy efforts on reimbursement issues, for example, have prevented millions of dollars in payment cuts, something hugely important to members in community practice.

However, many older surgeons will recall a period when only a select few could join the Society for Vascular Surgery as it was then constituted. Entry was reserved for nationally recognized researchers or those with an extensive list of publications. At that time, it was even difficult to become a member of the International Society for Cardiovascular Surgery. Community surgeons who had limited or few current publications were almost totally excluded. That was the impetus for community surgeons to form the Society for Clinical Vascular Surgery. However, some years back the SVS expanded beyond just the meeting and sought to be inclusive rather than restrictive. Membership is now virtually guaranteed to all board-certified vascular surgeons in good standing. Even members of allied health groups such as nurse practitioners and physician assistants are encouraged to become affiliate members. The SVS inspires female and minority medical students to become vascular surgeons and future members.

Further, 7 years ago, current President Bruce Perler, then chair of the Clinical Practice Council, initiated the Community Practice Advisory Committee in an effort to address the concerns of community members. I had the privilege of being its first chairperson. The current chairperson of that committee, Richard Lynn, now serves on the Board of the Society. Additionally, the SVS has made a concerted effort to add community surgeons to all of its committees.

Even the annual meeting has increasingly added multiple sessions addressing topics of interest to community surgeons. As attendance at these session proves, academic and employed physicians have found them to be equally informative. This is the result of the changing economic and health care environment that has blurred the lines between academic and nonacademic practices. Is there, then, any real division that separates the university surgeon from his or her community counterpart? Personally I believe there is none. If there is, it is simply a historical memory that has failed to disappear when confronted with the reality of the present.

However, Carlo Dall’Olmo and Dennis Gable, community surgeons who have been very active in SVS leadership positions (Carlo as Chair of the PAC and Dennis as Membership Chair), both recognize the absence of community surgeons on the SVS Executive Committee. Does this imply a conspiracy? Of course not! Rather, it is a result of the many factors briefly outlined in their letters. I have had the benefit of discussions with both men, as well as current and past SVS Presidents, so perhaps I can paraphrase their thoughts on this issue.

Carlo suggests that it is a result of a governance structure that rewards leadership positions based not only on service to the Society but also on academic achievements. He, as well as many others, suggests that our leaders should be elected, based not only on their publications and research, but also they must have proven dedication to the Society as well as providing a manifesto or platform explaining their goals for its future. Indeed, most if not all current and past executive members have been some of the most prolific researchers and have also effectively served on multiple committees over many years. If not for their hard work (unpaid and purely voluntary), our Society would never be in the viable situation it is now. We certainly owe a great deal of gratitude to the many academics who have so effectively stewarded our organization.

Some also have questioned whether busy community practice surgeons will be equally able to comply with the time-consuming demands of the Executive Committee. The presidency is almost a full-time position, yet it remains unpaid. Accordingly, a private-practice surgeon will need the backing of his or her partners or sufficient finances to counter the loss of income. Academic surgeons also have busy lives running departments, lecturing students, and operating on the most-challenging cases. Surely then, if candidates have proven themselves through years of conscientious labor on SVS committees, the manner of their employment or source of income should not influence their electability.

Dennis also explains that many private practice surgeons have a laissez-faire attitude leaving the multitude of committee appointments to these dedicated academic surgeons. On the contrary, I have spoken with numerous community surgeons who claim to have volunteered for committee or leadership positions and have not yet been appointed. Perhaps it is a self-fulfilling situation. The composition of the SVS Nominating Committee, which proposes the slate for SVS officers, originally comprised the immediate past, current, and future presidents. The composition was changed several years ago and now includes the two immediate past presidents, a representative from the affiliated vascular societies, a representative from the SVS Councils, and recently, an at-large member elected by the SVS membership. The objective was to encourage participation from someone, possibly a community practice surgeon, who had the support of the general membership.

However, it is problematic for community surgeons to gain sufficient exposure or national recognition to be elected unless they publish and lecture prolifically. Since the nominating committee has always consisted of academic surgeons, it could be argued that they would necessarily favor academics. On the other hand, such favoritism may be based simply on the fact that they are more familiar with one another. It is conceivable that as more community surgeons prove their organizational skills by serving on various committees, some will become well known and electable. As yet, the current pool of eligible community surgeons is small, whereas there are many academic surgeons clearly deserving of appointment.

Interestingly, there are now academic members of the current Executive Committee who were formerly in private practice or are currently in situations that can be regarded as both academic and community based. This suggests that the lines between academic and community practice have blurred sufficiently enough that we should no longer consider ourselves as belonging to different camps. Also, for the last 3 years, I have been a guest at the SVS Board of Directors meetings, where I have witnessed intense deliberation on multiple issues of equal concern to both academic and private surgeons. In fact, some current leaders are so certain that we are all the same that they question whether the addition of community surgeons will add new insights that might modify the daily function and future agenda of the SVS.

Consistent with the necessity for full disclosure, I am a community-practice surgeon, although I was in full-time academics for the first 6 years of my practice and now hold a position as a clinical professor at Florida State University Medical School in Tallahassee. With this background, I suggest that negating the value of community input is an incorrect concept. Private practice has many challenges, which include diverse issues such as maintaining IT departments, staffing, electronic medical records, Stark issues, malpractice insurance requirements, PQRS requirements, contract issues, partnership contracts, and competition with other specialists and hospital groups. Even current training paradigms are affecting private practitioners. Accordingly, it is imperative that their concerns are heard at the highest level. Perhaps, too, having community-practice representation on the Executive would be seen as a positive impetus to encourage more unaffiliated community doctors to join the Society.In September, Pope Francis visited America. During his speech to the United Nations, he made the following statement: “The contemporary world, with its open wounds which affect so many of our brothers and sisters, commands that we confront every form of polarization which would divide it into these two camps.”

Vascular surgeons and the Society for Vascular Surgery would do well to heed his words.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.

In this month’s Vascular Specialist, there are two letters to the editor that seem to imply a division in the SVS membership. The letters indirectly suggest that the SVS comprises two camps, on the one hand, academics, and on the other, community-based physicians. Further, although the majority of the membership comprises primarily of nonacademic surgeons, the leadership is, and will remain, predominantly composed of University-employed physicians. Implicit also is that there may not be a common agenda.

However, many questions come to mind: Are we truly a house divided? If so, how did this come about? Do community and academic surgeons indeed have different concerns that split us into camps? If so, how can we come together because the aphorism “United we stand, divided we fall” will have critical implications for the future of our specialty.

Dennis Gable writes that “the SVS is often (and historically) thought of as a society reserved for academic surgeons” because it is regarded solely as a vehicle to arrange a national academic meeting (the VAM). However, he counters that incorrect assessment by describing many fundamentally important roles that the SVS plays in the daily lives of practicing vascular surgeons. He encourages members to go online (at www.vascularweb.org) and see for themselves all that the SVS is doing for vascular surgery, vascular surgeons and their patients. The Society’s strong advocacy efforts on reimbursement issues, for example, have prevented millions of dollars in payment cuts, something hugely important to members in community practice.

However, many older surgeons will recall a period when only a select few could join the Society for Vascular Surgery as it was then constituted. Entry was reserved for nationally recognized researchers or those with an extensive list of publications. At that time, it was even difficult to become a member of the International Society for Cardiovascular Surgery. Community surgeons who had limited or few current publications were almost totally excluded. That was the impetus for community surgeons to form the Society for Clinical Vascular Surgery. However, some years back the SVS expanded beyond just the meeting and sought to be inclusive rather than restrictive. Membership is now virtually guaranteed to all board-certified vascular surgeons in good standing. Even members of allied health groups such as nurse practitioners and physician assistants are encouraged to become affiliate members. The SVS inspires female and minority medical students to become vascular surgeons and future members.

Further, 7 years ago, current President Bruce Perler, then chair of the Clinical Practice Council, initiated the Community Practice Advisory Committee in an effort to address the concerns of community members. I had the privilege of being its first chairperson. The current chairperson of that committee, Richard Lynn, now serves on the Board of the Society. Additionally, the SVS has made a concerted effort to add community surgeons to all of its committees.

Even the annual meeting has increasingly added multiple sessions addressing topics of interest to community surgeons. As attendance at these session proves, academic and employed physicians have found them to be equally informative. This is the result of the changing economic and health care environment that has blurred the lines between academic and nonacademic practices. Is there, then, any real division that separates the university surgeon from his or her community counterpart? Personally I believe there is none. If there is, it is simply a historical memory that has failed to disappear when confronted with the reality of the present.

However, Carlo Dall’Olmo and Dennis Gable, community surgeons who have been very active in SVS leadership positions (Carlo as Chair of the PAC and Dennis as Membership Chair), both recognize the absence of community surgeons on the SVS Executive Committee. Does this imply a conspiracy? Of course not! Rather, it is a result of the many factors briefly outlined in their letters. I have had the benefit of discussions with both men, as well as current and past SVS Presidents, so perhaps I can paraphrase their thoughts on this issue.

Carlo suggests that it is a result of a governance structure that rewards leadership positions based not only on service to the Society but also on academic achievements. He, as well as many others, suggests that our leaders should be elected, based not only on their publications and research, but also they must have proven dedication to the Society as well as providing a manifesto or platform explaining their goals for its future. Indeed, most if not all current and past executive members have been some of the most prolific researchers and have also effectively served on multiple committees over many years. If not for their hard work (unpaid and purely voluntary), our Society would never be in the viable situation it is now. We certainly owe a great deal of gratitude to the many academics who have so effectively stewarded our organization.

Some also have questioned whether busy community practice surgeons will be equally able to comply with the time-consuming demands of the Executive Committee. The presidency is almost a full-time position, yet it remains unpaid. Accordingly, a private-practice surgeon will need the backing of his or her partners or sufficient finances to counter the loss of income. Academic surgeons also have busy lives running departments, lecturing students, and operating on the most-challenging cases. Surely then, if candidates have proven themselves through years of conscientious labor on SVS committees, the manner of their employment or source of income should not influence their electability.

Dennis also explains that many private practice surgeons have a laissez-faire attitude leaving the multitude of committee appointments to these dedicated academic surgeons. On the contrary, I have spoken with numerous community surgeons who claim to have volunteered for committee or leadership positions and have not yet been appointed. Perhaps it is a self-fulfilling situation. The composition of the SVS Nominating Committee, which proposes the slate for SVS officers, originally comprised the immediate past, current, and future presidents. The composition was changed several years ago and now includes the two immediate past presidents, a representative from the affiliated vascular societies, a representative from the SVS Councils, and recently, an at-large member elected by the SVS membership. The objective was to encourage participation from someone, possibly a community practice surgeon, who had the support of the general membership.

However, it is problematic for community surgeons to gain sufficient exposure or national recognition to be elected unless they publish and lecture prolifically. Since the nominating committee has always consisted of academic surgeons, it could be argued that they would necessarily favor academics. On the other hand, such favoritism may be based simply on the fact that they are more familiar with one another. It is conceivable that as more community surgeons prove their organizational skills by serving on various committees, some will become well known and electable. As yet, the current pool of eligible community surgeons is small, whereas there are many academic surgeons clearly deserving of appointment.

Interestingly, there are now academic members of the current Executive Committee who were formerly in private practice or are currently in situations that can be regarded as both academic and community based. This suggests that the lines between academic and community practice have blurred sufficiently enough that we should no longer consider ourselves as belonging to different camps. Also, for the last 3 years, I have been a guest at the SVS Board of Directors meetings, where I have witnessed intense deliberation on multiple issues of equal concern to both academic and private surgeons. In fact, some current leaders are so certain that we are all the same that they question whether the addition of community surgeons will add new insights that might modify the daily function and future agenda of the SVS.

Consistent with the necessity for full disclosure, I am a community-practice surgeon, although I was in full-time academics for the first 6 years of my practice and now hold a position as a clinical professor at Florida State University Medical School in Tallahassee. With this background, I suggest that negating the value of community input is an incorrect concept. Private practice has many challenges, which include diverse issues such as maintaining IT departments, staffing, electronic medical records, Stark issues, malpractice insurance requirements, PQRS requirements, contract issues, partnership contracts, and competition with other specialists and hospital groups. Even current training paradigms are affecting private practitioners. Accordingly, it is imperative that their concerns are heard at the highest level. Perhaps, too, having community-practice representation on the Executive would be seen as a positive impetus to encourage more unaffiliated community doctors to join the Society.In September, Pope Francis visited America. During his speech to the United Nations, he made the following statement: “The contemporary world, with its open wounds which affect so many of our brothers and sisters, commands that we confront every form of polarization which would divide it into these two camps.”

Vascular surgeons and the Society for Vascular Surgery would do well to heed his words.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.

In this month’s Vascular Specialist, there are two letters to the editor that seem to imply a division in the SVS membership. The letters indirectly suggest that the SVS comprises two camps, on the one hand, academics, and on the other, community-based physicians. Further, although the majority of the membership comprises primarily of nonacademic surgeons, the leadership is, and will remain, predominantly composed of University-employed physicians. Implicit also is that there may not be a common agenda.

However, many questions come to mind: Are we truly a house divided? If so, how did this come about? Do community and academic surgeons indeed have different concerns that split us into camps? If so, how can we come together because the aphorism “United we stand, divided we fall” will have critical implications for the future of our specialty.

Dennis Gable writes that “the SVS is often (and historically) thought of as a society reserved for academic surgeons” because it is regarded solely as a vehicle to arrange a national academic meeting (the VAM). However, he counters that incorrect assessment by describing many fundamentally important roles that the SVS plays in the daily lives of practicing vascular surgeons. He encourages members to go online (at www.vascularweb.org) and see for themselves all that the SVS is doing for vascular surgery, vascular surgeons and their patients. The Society’s strong advocacy efforts on reimbursement issues, for example, have prevented millions of dollars in payment cuts, something hugely important to members in community practice.

However, many older surgeons will recall a period when only a select few could join the Society for Vascular Surgery as it was then constituted. Entry was reserved for nationally recognized researchers or those with an extensive list of publications. At that time, it was even difficult to become a member of the International Society for Cardiovascular Surgery. Community surgeons who had limited or few current publications were almost totally excluded. That was the impetus for community surgeons to form the Society for Clinical Vascular Surgery. However, some years back the SVS expanded beyond just the meeting and sought to be inclusive rather than restrictive. Membership is now virtually guaranteed to all board-certified vascular surgeons in good standing. Even members of allied health groups such as nurse practitioners and physician assistants are encouraged to become affiliate members. The SVS inspires female and minority medical students to become vascular surgeons and future members.

Further, 7 years ago, current President Bruce Perler, then chair of the Clinical Practice Council, initiated the Community Practice Advisory Committee in an effort to address the concerns of community members. I had the privilege of being its first chairperson. The current chairperson of that committee, Richard Lynn, now serves on the Board of the Society. Additionally, the SVS has made a concerted effort to add community surgeons to all of its committees.

Even the annual meeting has increasingly added multiple sessions addressing topics of interest to community surgeons. As attendance at these session proves, academic and employed physicians have found them to be equally informative. This is the result of the changing economic and health care environment that has blurred the lines between academic and nonacademic practices. Is there, then, any real division that separates the university surgeon from his or her community counterpart? Personally I believe there is none. If there is, it is simply a historical memory that has failed to disappear when confronted with the reality of the present.

However, Carlo Dall’Olmo and Dennis Gable, community surgeons who have been very active in SVS leadership positions (Carlo as Chair of the PAC and Dennis as Membership Chair), both recognize the absence of community surgeons on the SVS Executive Committee. Does this imply a conspiracy? Of course not! Rather, it is a result of the many factors briefly outlined in their letters. I have had the benefit of discussions with both men, as well as current and past SVS Presidents, so perhaps I can paraphrase their thoughts on this issue.

Carlo suggests that it is a result of a governance structure that rewards leadership positions based not only on service to the Society but also on academic achievements. He, as well as many others, suggests that our leaders should be elected, based not only on their publications and research, but also they must have proven dedication to the Society as well as providing a manifesto or platform explaining their goals for its future. Indeed, most if not all current and past executive members have been some of the most prolific researchers and have also effectively served on multiple committees over many years. If not for their hard work (unpaid and purely voluntary), our Society would never be in the viable situation it is now. We certainly owe a great deal of gratitude to the many academics who have so effectively stewarded our organization.

Some also have questioned whether busy community practice surgeons will be equally able to comply with the time-consuming demands of the Executive Committee. The presidency is almost a full-time position, yet it remains unpaid. Accordingly, a private-practice surgeon will need the backing of his or her partners or sufficient finances to counter the loss of income. Academic surgeons also have busy lives running departments, lecturing students, and operating on the most-challenging cases. Surely then, if candidates have proven themselves through years of conscientious labor on SVS committees, the manner of their employment or source of income should not influence their electability.

Dennis also explains that many private practice surgeons have a laissez-faire attitude leaving the multitude of committee appointments to these dedicated academic surgeons. On the contrary, I have spoken with numerous community surgeons who claim to have volunteered for committee or leadership positions and have not yet been appointed. Perhaps it is a self-fulfilling situation. The composition of the SVS Nominating Committee, which proposes the slate for SVS officers, originally comprised the immediate past, current, and future presidents. The composition was changed several years ago and now includes the two immediate past presidents, a representative from the affiliated vascular societies, a representative from the SVS Councils, and recently, an at-large member elected by the SVS membership. The objective was to encourage participation from someone, possibly a community practice surgeon, who had the support of the general membership.

However, it is problematic for community surgeons to gain sufficient exposure or national recognition to be elected unless they publish and lecture prolifically. Since the nominating committee has always consisted of academic surgeons, it could be argued that they would necessarily favor academics. On the other hand, such favoritism may be based simply on the fact that they are more familiar with one another. It is conceivable that as more community surgeons prove their organizational skills by serving on various committees, some will become well known and electable. As yet, the current pool of eligible community surgeons is small, whereas there are many academic surgeons clearly deserving of appointment.

Interestingly, there are now academic members of the current Executive Committee who were formerly in private practice or are currently in situations that can be regarded as both academic and community based. This suggests that the lines between academic and community practice have blurred sufficiently enough that we should no longer consider ourselves as belonging to different camps. Also, for the last 3 years, I have been a guest at the SVS Board of Directors meetings, where I have witnessed intense deliberation on multiple issues of equal concern to both academic and private surgeons. In fact, some current leaders are so certain that we are all the same that they question whether the addition of community surgeons will add new insights that might modify the daily function and future agenda of the SVS.

Consistent with the necessity for full disclosure, I am a community-practice surgeon, although I was in full-time academics for the first 6 years of my practice and now hold a position as a clinical professor at Florida State University Medical School in Tallahassee. With this background, I suggest that negating the value of community input is an incorrect concept. Private practice has many challenges, which include diverse issues such as maintaining IT departments, staffing, electronic medical records, Stark issues, malpractice insurance requirements, PQRS requirements, contract issues, partnership contracts, and competition with other specialists and hospital groups. Even current training paradigms are affecting private practitioners. Accordingly, it is imperative that their concerns are heard at the highest level. Perhaps, too, having community-practice representation on the Executive would be seen as a positive impetus to encourage more unaffiliated community doctors to join the Society.In September, Pope Francis visited America. During his speech to the United Nations, he made the following statement: “The contemporary world, with its open wounds which affect so many of our brothers and sisters, commands that we confront every form of polarization which would divide it into these two camps.”

Vascular surgeons and the Society for Vascular Surgery would do well to heed his words.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.

The United States Preventive Services Task Force (USPSTF) recently issued a draft document recommending against screening for carotid artery disease in asymptomatic patients.

The draft implies that ultrasonography in the general population, where carotid artery stenosis prevalence is low, yields "many false-positive results." Moreover the USPSTF concludes that there is "adequate evidence" that both testing for carotid artery stenosis and treating carotid artery stenosis "can cause harm."

How is it that a test most vascular surgeons consider reliable can be so inaccurate on a national level? How can screening duplex ultrasonography have such a negative impact? I believe that the answer is simple. It is not that the test is flawed or that the treatment is overly risky. It is that those who perform the tests and subsequent interventions are not vascular surgeons. Vascular surgeons pioneered ultrasound evaluation of the carotid artery and, for the most part, continue to offer reliable tests and subsequent treatments. However, over the past few years, we have become marginalized. Now entrepreneurs run mobile labs often using outdated equipment and poorly supervised technologists. They wheel their machines into primary care doctors’ offices for the day, where patients who do not need testing are nevertheless scanned. The scans are then read offsite by who-knows-who with inexact results commensurate with the poorly performed studies. I suspect that many of these tests are not even interpreted by a physician who simply rubber stamps the technologist’s preliminary study. No wonder the USPSTF has its concerns.

It is not only the mobile labs that are the problem. Family practice clinics are also investing in machines and relying on a technologist’s interpretation. Some podiatrists are now advertising that they are experts in evaluating lower-extremity ischemia and venous disease. Believe it or not, their competition comes from gynecologists and orthopedists. Cardiologists seem to be more interested in carotid and lower-extremity arteries than the coronaries. Further, having direct control of the patient and the interpretation of an ultrasound test, it becomes relatively straightforward for them to "justify" a carotid artery stent.

Vascular surgeons and registered vascular technologists have endeavored to refine diagnostic parameters that will improve the accuracy of these tests. Most use the best equipment and attend many hours of continuing education. They voluntarily go through the arduous process of having their vascular lab certified by the Intersocietal Accreditation Commission so as to be sure that they are providing optimal services and accurate diagnoses. Dr. Eric Topol, a noted cardiologist, has begun promoting the concept of an ultrasound that can be attached to an iPhone.

The question, however, is whether an untrained physician using an inexpensive hand-held ultrasound can still make an accurate diagnosis. And will this test be reimbursed no matter what the quality, or the outcome of such a study on the patient?

Fortunately those "I-Sound" devices may still be far off in our future. However, even now, surgeons will have a patient referred to them for treatment of a critical carotid stenosis that they cannot replicate with a confirmatory ultrasound in their own lab. This has become so common an occurrence that our group always repeats the outside test. In so doing, we run the risk of antagonizing the referring doctor, confusing the patient, and being told by the insurance program that we are performing an unnecessary reevaluation. To add insult to injury, we are usually not paid for this confirmatory test. It appears that insurance carriers would rather pay for an unnecessary endarterectomy or stent, with the possibility of stroke or death, rather than pay for a repeat test that might have prevented the procedure in the first place.

In an upcoming edition of Vascular Specialist, we will provide a "Point-Counterpoint" discussion on the value of screening for carotid disease and the merit of the USPSTF document. But, in the meantime, what are we to do about these subpar labs, their nondiagnostic tests and subsequent unnecessary and poorly performed interventions? Can we really stop this abuse? I believe we can. As I mentioned, we already have an accreditation body to evaluate diagnostic vascular facilities.

What we need to do is convince insurance companies and the Centers for Medicare & Medicaid Services that only certified labs should be permitted to carry out these studies. Further, only trained, certified specialists should be allowed to perform carotid stenting and carotid artery surgery. Finally, we need to educate patients that all tests are not generic. They should insist on having their carotid artery ultrasounds carried out by a vascular surgeon or, at the very least, having it done in an accredited vascular lab.

The United States Preventive Services Task Force (USPSTF) recently issued a draft document recommending against screening for carotid artery disease in asymptomatic patients.

The draft implies that ultrasonography in the general population, where carotid artery stenosis prevalence is low, yields "many false-positive results." Moreover the USPSTF concludes that there is "adequate evidence" that both testing for carotid artery stenosis and treating carotid artery stenosis "can cause harm."

How is it that a test most vascular surgeons consider reliable can be so inaccurate on a national level? How can screening duplex ultrasonography have such a negative impact? I believe that the answer is simple. It is not that the test is flawed or that the treatment is overly risky. It is that those who perform the tests and subsequent interventions are not vascular surgeons. Vascular surgeons pioneered ultrasound evaluation of the carotid artery and, for the most part, continue to offer reliable tests and subsequent treatments. However, over the past few years, we have become marginalized. Now entrepreneurs run mobile labs often using outdated equipment and poorly supervised technologists. They wheel their machines into primary care doctors’ offices for the day, where patients who do not need testing are nevertheless scanned. The scans are then read offsite by who-knows-who with inexact results commensurate with the poorly performed studies. I suspect that many of these tests are not even interpreted by a physician who simply rubber stamps the technologist’s preliminary study. No wonder the USPSTF has its concerns.

It is not only the mobile labs that are the problem. Family practice clinics are also investing in machines and relying on a technologist’s interpretation. Some podiatrists are now advertising that they are experts in evaluating lower-extremity ischemia and venous disease. Believe it or not, their competition comes from gynecologists and orthopedists. Cardiologists seem to be more interested in carotid and lower-extremity arteries than the coronaries. Further, having direct control of the patient and the interpretation of an ultrasound test, it becomes relatively straightforward for them to "justify" a carotid artery stent.

Vascular surgeons and registered vascular technologists have endeavored to refine diagnostic parameters that will improve the accuracy of these tests. Most use the best equipment and attend many hours of continuing education. They voluntarily go through the arduous process of having their vascular lab certified by the Intersocietal Accreditation Commission so as to be sure that they are providing optimal services and accurate diagnoses. Dr. Eric Topol, a noted cardiologist, has begun promoting the concept of an ultrasound that can be attached to an iPhone.

The question, however, is whether an untrained physician using an inexpensive hand-held ultrasound can still make an accurate diagnosis. And will this test be reimbursed no matter what the quality, or the outcome of such a study on the patient?

Fortunately those "I-Sound" devices may still be far off in our future. However, even now, surgeons will have a patient referred to them for treatment of a critical carotid stenosis that they cannot replicate with a confirmatory ultrasound in their own lab. This has become so common an occurrence that our group always repeats the outside test. In so doing, we run the risk of antagonizing the referring doctor, confusing the patient, and being told by the insurance program that we are performing an unnecessary reevaluation. To add insult to injury, we are usually not paid for this confirmatory test. It appears that insurance carriers would rather pay for an unnecessary endarterectomy or stent, with the possibility of stroke or death, rather than pay for a repeat test that might have prevented the procedure in the first place.

In an upcoming edition of Vascular Specialist, we will provide a "Point-Counterpoint" discussion on the value of screening for carotid disease and the merit of the USPSTF document. But, in the meantime, what are we to do about these subpar labs, their nondiagnostic tests and subsequent unnecessary and poorly performed interventions? Can we really stop this abuse? I believe we can. As I mentioned, we already have an accreditation body to evaluate diagnostic vascular facilities.

What we need to do is convince insurance companies and the Centers for Medicare & Medicaid Services that only certified labs should be permitted to carry out these studies. Further, only trained, certified specialists should be allowed to perform carotid stenting and carotid artery surgery. Finally, we need to educate patients that all tests are not generic. They should insist on having their carotid artery ultrasounds carried out by a vascular surgeon or, at the very least, having it done in an accredited vascular lab.

The United States Preventive Services Task Force (USPSTF) recently issued a draft document recommending against screening for carotid artery disease in asymptomatic patients.

The draft implies that ultrasonography in the general population, where carotid artery stenosis prevalence is low, yields "many false-positive results." Moreover the USPSTF concludes that there is "adequate evidence" that both testing for carotid artery stenosis and treating carotid artery stenosis "can cause harm."

How is it that a test most vascular surgeons consider reliable can be so inaccurate on a national level? How can screening duplex ultrasonography have such a negative impact? I believe that the answer is simple. It is not that the test is flawed or that the treatment is overly risky. It is that those who perform the tests and subsequent interventions are not vascular surgeons. Vascular surgeons pioneered ultrasound evaluation of the carotid artery and, for the most part, continue to offer reliable tests and subsequent treatments. However, over the past few years, we have become marginalized. Now entrepreneurs run mobile labs often using outdated equipment and poorly supervised technologists. They wheel their machines into primary care doctors’ offices for the day, where patients who do not need testing are nevertheless scanned. The scans are then read offsite by who-knows-who with inexact results commensurate with the poorly performed studies. I suspect that many of these tests are not even interpreted by a physician who simply rubber stamps the technologist’s preliminary study. No wonder the USPSTF has its concerns.

It is not only the mobile labs that are the problem. Family practice clinics are also investing in machines and relying on a technologist’s interpretation. Some podiatrists are now advertising that they are experts in evaluating lower-extremity ischemia and venous disease. Believe it or not, their competition comes from gynecologists and orthopedists. Cardiologists seem to be more interested in carotid and lower-extremity arteries than the coronaries. Further, having direct control of the patient and the interpretation of an ultrasound test, it becomes relatively straightforward for them to "justify" a carotid artery stent.

Vascular surgeons and registered vascular technologists have endeavored to refine diagnostic parameters that will improve the accuracy of these tests. Most use the best equipment and attend many hours of continuing education. They voluntarily go through the arduous process of having their vascular lab certified by the Intersocietal Accreditation Commission so as to be sure that they are providing optimal services and accurate diagnoses. Dr. Eric Topol, a noted cardiologist, has begun promoting the concept of an ultrasound that can be attached to an iPhone.

The question, however, is whether an untrained physician using an inexpensive hand-held ultrasound can still make an accurate diagnosis. And will this test be reimbursed no matter what the quality, or the outcome of such a study on the patient?

Fortunately those "I-Sound" devices may still be far off in our future. However, even now, surgeons will have a patient referred to them for treatment of a critical carotid stenosis that they cannot replicate with a confirmatory ultrasound in their own lab. This has become so common an occurrence that our group always repeats the outside test. In so doing, we run the risk of antagonizing the referring doctor, confusing the patient, and being told by the insurance program that we are performing an unnecessary reevaluation. To add insult to injury, we are usually not paid for this confirmatory test. It appears that insurance carriers would rather pay for an unnecessary endarterectomy or stent, with the possibility of stroke or death, rather than pay for a repeat test that might have prevented the procedure in the first place.

In an upcoming edition of Vascular Specialist, we will provide a "Point-Counterpoint" discussion on the value of screening for carotid disease and the merit of the USPSTF document. But, in the meantime, what are we to do about these subpar labs, their nondiagnostic tests and subsequent unnecessary and poorly performed interventions? Can we really stop this abuse? I believe we can. As I mentioned, we already have an accreditation body to evaluate diagnostic vascular facilities.

What we need to do is convince insurance companies and the Centers for Medicare & Medicaid Services that only certified labs should be permitted to carry out these studies. Further, only trained, certified specialists should be allowed to perform carotid stenting and carotid artery surgery. Finally, we need to educate patients that all tests are not generic. They should insist on having their carotid artery ultrasounds carried out by a vascular surgeon or, at the very least, having it done in an accredited vascular lab.

In this online issue of Vascular Specialist, we mourn the passing of five pioneer vascular surgeons. One of these, Dr. James DeWeese, worked with Dr. George Johnson to complete a book after the death of another renowned father of vascular surgery, Dr. Andrew Dale. The book's title, "Band of Brothers: Creators of Modern Vascular Surgery,"was based on words by Shakespeare. It describes the lives and accomplishments of some of the founders of our specialty. Sadly, many of these great men have passed on.

Now, in just a few short months, we have lost five more innovators in our field. From their obituaries included in this online edition of Vascular Specialist, older surgeons will remember, and younger surgeons will learn about these fine men. Each in their own way made enormous contributions to the developing field of vascular and endovascular surgery. To single out just one of their accomplishments would be to diminish their other successes.

But how can we overlook Dr. David S. Sumner's book, coauthored with Dr. D. E. Strandness, "Haemodynamics for Surgeons," and his help in developing noninvasive vascular tests; Dr. Wylie F. Barker's monograph "Surgical Treatment of Peripheral Vascular Disease" and his first "endovascular" approach to removing femoropopliteal plaque; Dr. Robert B. Rutherford's many editions of his eponymous "Vascular Surgery"and reporting standards for vascular disease and its treatment; Dr. DeWeese's proving the concept of venous interruption for preventing pulmonary embolism and his development of training paradigms for vascular surgeons; or Dr. Roy Greenberg's untimely illness, which still did not prevent him from developing new endovascular methods for treating complex aortic aneurysms.

But as we mourn the passing of these great men, I cannot help thinking that the title of the book "Band of Brothers: Creators of Modern Vascular Surgery" is now an anachronism. Although apt for that generation, its title contains a message that I believe is true for our times.

Let me explain. In those pioneering early days of vascular surgery, our numbers were small. Today, although the membership of the Society for Vascular Surgery approximates 5,000, we are still the smallest recognized medical specialty. On occasion we bemoan this fact, since our small numbers make it difficult for our collective voice to be recognized by organized medicine and our government.

However our small size is accompanied by some profound benefits. One of these, especially, is our ability to maintain collegial and working relationships that members of large societies may never enjoy. I was recently at the Southern Association for Vascular Surgery annual meeting at the Breakers in Florida. As I looked around the lecture theater and later at a cocktail party, I realized that we are now not just a "band of brothers" but rather a "band of brothers and sisters."

Whereas in the pioneer days of our specialty men predominated, now women also play an essential role in vascular disease management. It would be unrealistic to mention all the women who have become so successful in our field, but how can I not highlight the fact that the current president of the Society for Vascular Surgery is Dr. Julie Freischlag and that many chairs of vascular surgery are now held by women? It is also obvious that fellowship programs are filling with aspiring women vascular surgeons.

But it's not only the changing ratio of men to women that was so visible, but also the diversity of our membership, with surgeons of every background enjoying the communal spirit so obvious at these regional and national meetings. It was especially gratifying to watch the faces of our members as they interacted. I saw the pleasure they exhibited when meeting an old friend or on learning of the successes of a colleague's family. I overheard enthusiastic and often heated arguments about various procedures, yet it was clear that they still delighted in the special camaraderie of surgeons dedicated to treating vascular disorders.

Yes, indeed we are a special group of doctors. We may often disagree with each other on medical matters, but we still enjoy each other's company and work together to better the lives of our patients. It is not surprising, then, that we are devastated by the loss of friends and colleagues. In June at the Vascular Annual Meeting, we will bow our heads in a moment of silence and pay respect to those that have passed, famous or not. By this action we also commit to continue our thriving specialty, now comprised of men and women of diverse cultures and backgrounds.

So, perhaps in the not too distant future, another author will write a book whose title, inspired by Shakespeare, will be "We Band of Brothers and Sisters: Creators of Modern Vascular Surgery."

Dr. Samson is a clinical professor of surgery (vascular), Florida State University School of Medicine, Tallahassee; a member of Sarasota (Fla.) Vascular Specialists; and the medical editor of Vascular Specialist.

In this online issue of Vascular Specialist, we mourn the passing of five pioneer vascular surgeons. One of these, Dr. James DeWeese, worked with Dr. George Johnson to complete a book after the death of another renowned father of vascular surgery, Dr. Andrew Dale. The book's title, "Band of Brothers: Creators of Modern Vascular Surgery,"was based on words by Shakespeare. It describes the lives and accomplishments of some of the founders of our specialty. Sadly, many of these great men have passed on.

Now, in just a few short months, we have lost five more innovators in our field. From their obituaries included in this online edition of Vascular Specialist, older surgeons will remember, and younger surgeons will learn about these fine men. Each in their own way made enormous contributions to the developing field of vascular and endovascular surgery. To single out just one of their accomplishments would be to diminish their other successes.

But how can we overlook Dr. David S. Sumner's book, coauthored with Dr. D. E. Strandness, "Haemodynamics for Surgeons," and his help in developing noninvasive vascular tests; Dr. Wylie F. Barker's monograph "Surgical Treatment of Peripheral Vascular Disease" and his first "endovascular" approach to removing femoropopliteal plaque; Dr. Robert B. Rutherford's many editions of his eponymous "Vascular Surgery"and reporting standards for vascular disease and its treatment; Dr. DeWeese's proving the concept of venous interruption for preventing pulmonary embolism and his development of training paradigms for vascular surgeons; or Dr. Roy Greenberg's untimely illness, which still did not prevent him from developing new endovascular methods for treating complex aortic aneurysms.

But as we mourn the passing of these great men, I cannot help thinking that the title of the book "Band of Brothers: Creators of Modern Vascular Surgery" is now an anachronism. Although apt for that generation, its title contains a message that I believe is true for our times.

Let me explain. In those pioneering early days of vascular surgery, our numbers were small. Today, although the membership of the Society for Vascular Surgery approximates 5,000, we are still the smallest recognized medical specialty. On occasion we bemoan this fact, since our small numbers make it difficult for our collective voice to be recognized by organized medicine and our government.

However our small size is accompanied by some profound benefits. One of these, especially, is our ability to maintain collegial and working relationships that members of large societies may never enjoy. I was recently at the Southern Association for Vascular Surgery annual meeting at the Breakers in Florida. As I looked around the lecture theater and later at a cocktail party, I realized that we are now not just a "band of brothers" but rather a "band of brothers and sisters."

Whereas in the pioneer days of our specialty men predominated, now women also play an essential role in vascular disease management. It would be unrealistic to mention all the women who have become so successful in our field, but how can I not highlight the fact that the current president of the Society for Vascular Surgery is Dr. Julie Freischlag and that many chairs of vascular surgery are now held by women? It is also obvious that fellowship programs are filling with aspiring women vascular surgeons.

But it's not only the changing ratio of men to women that was so visible, but also the diversity of our membership, with surgeons of every background enjoying the communal spirit so obvious at these regional and national meetings. It was especially gratifying to watch the faces of our members as they interacted. I saw the pleasure they exhibited when meeting an old friend or on learning of the successes of a colleague's family. I overheard enthusiastic and often heated arguments about various procedures, yet it was clear that they still delighted in the special camaraderie of surgeons dedicated to treating vascular disorders.

Yes, indeed we are a special group of doctors. We may often disagree with each other on medical matters, but we still enjoy each other's company and work together to better the lives of our patients. It is not surprising, then, that we are devastated by the loss of friends and colleagues. In June at the Vascular Annual Meeting, we will bow our heads in a moment of silence and pay respect to those that have passed, famous or not. By this action we also commit to continue our thriving specialty, now comprised of men and women of diverse cultures and backgrounds.

So, perhaps in the not too distant future, another author will write a book whose title, inspired by Shakespeare, will be "We Band of Brothers and Sisters: Creators of Modern Vascular Surgery."

Dr. Samson is a clinical professor of surgery (vascular), Florida State University School of Medicine, Tallahassee; a member of Sarasota (Fla.) Vascular Specialists; and the medical editor of Vascular Specialist.

In this online issue of Vascular Specialist, we mourn the passing of five pioneer vascular surgeons. One of these, Dr. James DeWeese, worked with Dr. George Johnson to complete a book after the death of another renowned father of vascular surgery, Dr. Andrew Dale. The book's title, "Band of Brothers: Creators of Modern Vascular Surgery,"was based on words by Shakespeare. It describes the lives and accomplishments of some of the founders of our specialty. Sadly, many of these great men have passed on.

Now, in just a few short months, we have lost five more innovators in our field. From their obituaries included in this online edition of Vascular Specialist, older surgeons will remember, and younger surgeons will learn about these fine men. Each in their own way made enormous contributions to the developing field of vascular and endovascular surgery. To single out just one of their accomplishments would be to diminish their other successes.

But how can we overlook Dr. David S. Sumner's book, coauthored with Dr. D. E. Strandness, "Haemodynamics for Surgeons," and his help in developing noninvasive vascular tests; Dr. Wylie F. Barker's monograph "Surgical Treatment of Peripheral Vascular Disease" and his first "endovascular" approach to removing femoropopliteal plaque; Dr. Robert B. Rutherford's many editions of his eponymous "Vascular Surgery"and reporting standards for vascular disease and its treatment; Dr. DeWeese's proving the concept of venous interruption for preventing pulmonary embolism and his development of training paradigms for vascular surgeons; or Dr. Roy Greenberg's untimely illness, which still did not prevent him from developing new endovascular methods for treating complex aortic aneurysms.

But as we mourn the passing of these great men, I cannot help thinking that the title of the book "Band of Brothers: Creators of Modern Vascular Surgery" is now an anachronism. Although apt for that generation, its title contains a message that I believe is true for our times.

Let me explain. In those pioneering early days of vascular surgery, our numbers were small. Today, although the membership of the Society for Vascular Surgery approximates 5,000, we are still the smallest recognized medical specialty. On occasion we bemoan this fact, since our small numbers make it difficult for our collective voice to be recognized by organized medicine and our government.

However our small size is accompanied by some profound benefits. One of these, especially, is our ability to maintain collegial and working relationships that members of large societies may never enjoy. I was recently at the Southern Association for Vascular Surgery annual meeting at the Breakers in Florida. As I looked around the lecture theater and later at a cocktail party, I realized that we are now not just a "band of brothers" but rather a "band of brothers and sisters."

Whereas in the pioneer days of our specialty men predominated, now women also play an essential role in vascular disease management. It would be unrealistic to mention all the women who have become so successful in our field, but how can I not highlight the fact that the current president of the Society for Vascular Surgery is Dr. Julie Freischlag and that many chairs of vascular surgery are now held by women? It is also obvious that fellowship programs are filling with aspiring women vascular surgeons.

But it's not only the changing ratio of men to women that was so visible, but also the diversity of our membership, with surgeons of every background enjoying the communal spirit so obvious at these regional and national meetings. It was especially gratifying to watch the faces of our members as they interacted. I saw the pleasure they exhibited when meeting an old friend or on learning of the successes of a colleague's family. I overheard enthusiastic and often heated arguments about various procedures, yet it was clear that they still delighted in the special camaraderie of surgeons dedicated to treating vascular disorders.

Yes, indeed we are a special group of doctors. We may often disagree with each other on medical matters, but we still enjoy each other's company and work together to better the lives of our patients. It is not surprising, then, that we are devastated by the loss of friends and colleagues. In June at the Vascular Annual Meeting, we will bow our heads in a moment of silence and pay respect to those that have passed, famous or not. By this action we also commit to continue our thriving specialty, now comprised of men and women of diverse cultures and backgrounds.

So, perhaps in the not too distant future, another author will write a book whose title, inspired by Shakespeare, will be "We Band of Brothers and Sisters: Creators of Modern Vascular Surgery."

Dr. Samson is a clinical professor of surgery (vascular), Florida State University School of Medicine, Tallahassee; a member of Sarasota (Fla.) Vascular Specialists; and the medical editor of Vascular Specialist.

[Read the Editorial/Take the Survey Below!]

Vascular surgeons, as well as related specialists, have increasingly become involved in the ownership of outpatient endovascular suites as proprietors (individual or partnered with other physicians or hospitals) or through lease arrangements. As such they would be responsible for the operation of the entity including any accreditation requirements, the financial aspects, quality, and patient safety.

There are some compelling reasons for physicians to become involved in these ventures. However, some have suggested that many of these suites will be established with minimal patient safeguards, outdated or inefficient technology, and ill-prepared or insufficient staff. Further, competition from these suites would reduce inpatient angiographic volume and experience as well as negatively impacting the finances of nearby hospitals. The main argument advanced by detractors of physician ownership has been that the profit motive may result in unnecessary testing or procedures and ?cherry picking? the less complicated and insured patient.

Accordingly, the Clinical Practice Council of the Society for Vascular Surgery (SVS) requested that a white paper be written to provide guidelines on the establishment and function of outpatient endovascular suites. However, there was a considerable debate as to what should be included in this white paper with some even suggesting that these outpatient suites should not be supported. Consequently, the Council requested the authors to initiate debate on the subject. Eventually the SVS may have sufficient information from its membership to produce a definitive statement as to the role and function of these outpatient facilities. Therefore, this editorial is based on the opinion of the authors. It is not a product of a systematic review nor is it a comprehensive analysis of the subject. Neither is it a product of the Society for Vascular Surgery. Readers are encouraged to consider the information presented, evaluate other material and reach their own conclusions. The authors would appreciate feedback in the form of letters to the editor of "Vascular Specialist" or directly to the authors. Their emails accompany this editorial.

What we think!

Diagnostic arteriography, venography, venous ablation, balloon angioplasty, atherectomy, vena caval filters, filter extraction, and stenting can all be performed in an outpatient setting and have been shown to be safe provided that standard quality controls are in place.

Compared to in-hospital centers, these free-standing outpatient suites may offer more efficient clinical operations, saving time and money for the patient, the surgeon and the insurance provider. Patients could benefit from the convenience and consistency of on-time appointments, convenient locations, shorter wait times, easier scheduling, onsite parking and less intimidating surroundings. The location and space allotted to the suite will vary. However, every effort should be made to assure that these positive attributes of outpatient endovascular suites are incorporated. The insurance carrier may benefit by reimbursing the center less than if the procedures were performed in a hospital. This would then result in lower co-pay for the patient and reduce overall premiums and the cost of healthcare. Vascular surgeons would have the convenience of working in a familiar facility usually in proximity to their clinic or private office. Importantly, they would work in an environment where they have direct control over safety, quality, personnel, equipment and cost.

Some endovascular suites are directly affiliated and attached to hospitals whereas others are independent and located at variable distances from hospitals or emergency facilities. Irrespective of ownership or location considerations, the prime concern for the vascular surgeon should be patient safety. Accordingly, special considerations may be required when these procedures are performed in locations at a distance from hospitals. Foremost, only procedures and technology proven to be safely performed as an outpatient should be considered for that setting. Newer technologies and procedures should probably not be utilized until their safety has been established. For example, although diagnostic carotid arteriography may be safely performed, stenting of carotid lesions probably should not be performed in these outpatient facilities at this time.

Procedures to prevent wrong side interventions, incorrect medication administration and other safety precautions, standard in hospital environments, must also be followed. Timely production of complete procedure reports and hard copy (digital or other media) of the images is strongly encouraged since these will most often be reviewed offsite.

Nowadays "cloud" storage of data may allow easy access to images although privacy concerns must be safeguarded. Tracking of complications such as hematoma formation, allergic reactions and other quality parameters such as contrast dosages, fluoroscopy time etc., should be performed on a regular basis.

In many states, complications must be reported to the relevant State Department of Health usually within 48 hours for their review. Most importantly, the endovascular suite should have in place a plan to deal with emergencies that may arise during or soon after a procedure such as cardio-pulmonary arrest, retroperitoneal bleeding, access site bleeding, false aneurysm, anaphylaxis etc. Standard care should incorporate having ACLS certified personnel present at all times with the ability to perform aggressive CPR including intubation, cardiac defibrillation etc.

Physicians administering or supervising moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia should have appropriate education and training. Since hospitalization may sometimes be necessary, a protocol for transfer of the patient to the nearest hospital should also be in place.

Transfer mechanisms should include the ability to offer advanced life support. A written agreement with the receiving hospital should be mandatory. If anesthesia services are provided arrangements regarding the role of these ancillary personnel should be contracted.

High quality X-ray imaging is a prerequisite for evaluation of vascular anatomy and the safe placement of catheters, stents and other intravascular devices. The goal should be to provide the best quality device with the least radiation exposure to staff and patients. Fixed overhead units are considered to offer better images, expedited procedures and potentially less radiation but newer portable units do provide acceptable images for most applications.

However, the choice of image intensifier (fixed overhead or portable) will often be based on space as well as cost considerations. No matter which device is chosen, standard radiation safety precautions should be followed (radiation badges, monthly dosimetry reports, lead lined rooms, etc).Every attempt should be made to assure that the quality and safety of the suite is equal, or superior ,to the in-hospital facility where the surgeon would otherwise be performing these procedures.

Disposable equipment (catheters, contrast agents, angioplasty balloons etc.) should all be present in sufficient quantity and quality to allow the procedure to be performed completely and safely. Strict inventory review must be done on a scheduled basis. There should be sufficient room to perform procedures from the neck, brachial, femoral or distal leg positions. Monitoring equipment including blood pressure, oxygenation, EKG etc should be present.

A regular maintenance program for all equipment must be in place. Satisfactory post-procedural areas should be available and staffed with protocols in place to reach the treating surgeon should an emergency occur. The treating surgeon must be available for a rapid response to unexpected complications that may be life or limb-threatening.

Standard precautions to protect patient confidentiality must be followed and all city, state or federal regulations governing these suites should be observed. Compliance with federal statutes such as the Anti-Kickback law and Stark law as well as individual State requirements must be in place

Physicians who own or lease these endovascular suites must assume an active role in managing the facility. This can result in increased productivity, quality and efficiency but can also result in real or perceived conflict of interest due to increased utilization and compensation.

However, the simplistic implication that physician ownership leads to increased utilization ignores the complexities involved in decision making that include multiple regulatory policies and clinical, non-financial, incentives. Irrespective, the vascular surgeon who receives remuneration for managing or owning the suite should fully disclose this arrangement to the patient or involved parties. Such relationships should be fully transparent to all stakeholders and comply with Federal and State statutes. Ultimately, the patient should be given the opportunity to decide on the location where they are to have the planned procedure.

In summary, then, we believe that many endovascular procedures can be safely performed in outpatient endovascular suites and that this can result in benefits for patient and surgeon. The author's support SVS members' use of these suites, regardless of ownership, as long as potential conflicts of interest are fully disclosed to the patient and provided that high quality care is provided safely and cost effectively.

[email protected]

[email protected]

[Please take the interactive 11-quesion survey below so SVS can know your views]

[Read the Editorial/Take the Survey Below!]

Vascular surgeons, as well as related specialists, have increasingly become involved in the ownership of outpatient endovascular suites as proprietors (individual or partnered with other physicians or hospitals) or through lease arrangements. As such they would be responsible for the operation of the entity including any accreditation requirements, the financial aspects, quality, and patient safety.

There are some compelling reasons for physicians to become involved in these ventures. However, some have suggested that many of these suites will be established with minimal patient safeguards, outdated or inefficient technology, and ill-prepared or insufficient staff. Further, competition from these suites would reduce inpatient angiographic volume and experience as well as negatively impacting the finances of nearby hospitals. The main argument advanced by detractors of physician ownership has been that the profit motive may result in unnecessary testing or procedures and ?cherry picking? the less complicated and insured patient.

Accordingly, the Clinical Practice Council of the Society for Vascular Surgery (SVS) requested that a white paper be written to provide guidelines on the establishment and function of outpatient endovascular suites. However, there was a considerable debate as to what should be included in this white paper with some even suggesting that these outpatient suites should not be supported. Consequently, the Council requested the authors to initiate debate on the subject. Eventually the SVS may have sufficient information from its membership to produce a definitive statement as to the role and function of these outpatient facilities. Therefore, this editorial is based on the opinion of the authors. It is not a product of a systematic review nor is it a comprehensive analysis of the subject. Neither is it a product of the Society for Vascular Surgery. Readers are encouraged to consider the information presented, evaluate other material and reach their own conclusions. The authors would appreciate feedback in the form of letters to the editor of "Vascular Specialist" or directly to the authors. Their emails accompany this editorial.

What we think!

Diagnostic arteriography, venography, venous ablation, balloon angioplasty, atherectomy, vena caval filters, filter extraction, and stenting can all be performed in an outpatient setting and have been shown to be safe provided that standard quality controls are in place.

Compared to in-hospital centers, these free-standing outpatient suites may offer more efficient clinical operations, saving time and money for the patient, the surgeon and the insurance provider. Patients could benefit from the convenience and consistency of on-time appointments, convenient locations, shorter wait times, easier scheduling, onsite parking and less intimidating surroundings. The location and space allotted to the suite will vary. However, every effort should be made to assure that these positive attributes of outpatient endovascular suites are incorporated. The insurance carrier may benefit by reimbursing the center less than if the procedures were performed in a hospital. This would then result in lower co-pay for the patient and reduce overall premiums and the cost of healthcare. Vascular surgeons would have the convenience of working in a familiar facility usually in proximity to their clinic or private office. Importantly, they would work in an environment where they have direct control over safety, quality, personnel, equipment and cost.

Some endovascular suites are directly affiliated and attached to hospitals whereas others are independent and located at variable distances from hospitals or emergency facilities. Irrespective of ownership or location considerations, the prime concern for the vascular surgeon should be patient safety. Accordingly, special considerations may be required when these procedures are performed in locations at a distance from hospitals. Foremost, only procedures and technology proven to be safely performed as an outpatient should be considered for that setting. Newer technologies and procedures should probably not be utilized until their safety has been established. For example, although diagnostic carotid arteriography may be safely performed, stenting of carotid lesions probably should not be performed in these outpatient facilities at this time.

Procedures to prevent wrong side interventions, incorrect medication administration and other safety precautions, standard in hospital environments, must also be followed. Timely production of complete procedure reports and hard copy (digital or other media) of the images is strongly encouraged since these will most often be reviewed offsite.

Nowadays "cloud" storage of data may allow easy access to images although privacy concerns must be safeguarded. Tracking of complications such as hematoma formation, allergic reactions and other quality parameters such as contrast dosages, fluoroscopy time etc., should be performed on a regular basis.

In many states, complications must be reported to the relevant State Department of Health usually within 48 hours for their review. Most importantly, the endovascular suite should have in place a plan to deal with emergencies that may arise during or soon after a procedure such as cardio-pulmonary arrest, retroperitoneal bleeding, access site bleeding, false aneurysm, anaphylaxis etc. Standard care should incorporate having ACLS certified personnel present at all times with the ability to perform aggressive CPR including intubation, cardiac defibrillation etc.

Physicians administering or supervising moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia should have appropriate education and training. Since hospitalization may sometimes be necessary, a protocol for transfer of the patient to the nearest hospital should also be in place.

Transfer mechanisms should include the ability to offer advanced life support. A written agreement with the receiving hospital should be mandatory. If anesthesia services are provided arrangements regarding the role of these ancillary personnel should be contracted.

High quality X-ray imaging is a prerequisite for evaluation of vascular anatomy and the safe placement of catheters, stents and other intravascular devices. The goal should be to provide the best quality device with the least radiation exposure to staff and patients. Fixed overhead units are considered to offer better images, expedited procedures and potentially less radiation but newer portable units do provide acceptable images for most applications.

However, the choice of image intensifier (fixed overhead or portable) will often be based on space as well as cost considerations. No matter which device is chosen, standard radiation safety precautions should be followed (radiation badges, monthly dosimetry reports, lead lined rooms, etc).Every attempt should be made to assure that the quality and safety of the suite is equal, or superior ,to the in-hospital facility where the surgeon would otherwise be performing these procedures.

Disposable equipment (catheters, contrast agents, angioplasty balloons etc.) should all be present in sufficient quantity and quality to allow the procedure to be performed completely and safely. Strict inventory review must be done on a scheduled basis. There should be sufficient room to perform procedures from the neck, brachial, femoral or distal leg positions. Monitoring equipment including blood pressure, oxygenation, EKG etc should be present.

A regular maintenance program for all equipment must be in place. Satisfactory post-procedural areas should be available and staffed with protocols in place to reach the treating surgeon should an emergency occur. The treating surgeon must be available for a rapid response to unexpected complications that may be life or limb-threatening.

Standard precautions to protect patient confidentiality must be followed and all city, state or federal regulations governing these suites should be observed. Compliance with federal statutes such as the Anti-Kickback law and Stark law as well as individual State requirements must be in place

Physicians who own or lease these endovascular suites must assume an active role in managing the facility. This can result in increased productivity, quality and efficiency but can also result in real or perceived conflict of interest due to increased utilization and compensation.

However, the simplistic implication that physician ownership leads to increased utilization ignores the complexities involved in decision making that include multiple regulatory policies and clinical, non-financial, incentives. Irrespective, the vascular surgeon who receives remuneration for managing or owning the suite should fully disclose this arrangement to the patient or involved parties. Such relationships should be fully transparent to all stakeholders and comply with Federal and State statutes. Ultimately, the patient should be given the opportunity to decide on the location where they are to have the planned procedure.

In summary, then, we believe that many endovascular procedures can be safely performed in outpatient endovascular suites and that this can result in benefits for patient and surgeon. The author's support SVS members' use of these suites, regardless of ownership, as long as potential conflicts of interest are fully disclosed to the patient and provided that high quality care is provided safely and cost effectively.

[email protected]

[email protected]

[Please take the interactive 11-quesion survey below so SVS can know your views]

[Read the Editorial/Take the Survey Below!]

Vascular surgeons, as well as related specialists, have increasingly become involved in the ownership of outpatient endovascular suites as proprietors (individual or partnered with other physicians or hospitals) or through lease arrangements. As such they would be responsible for the operation of the entity including any accreditation requirements, the financial aspects, quality, and patient safety.

There are some compelling reasons for physicians to become involved in these ventures. However, some have suggested that many of these suites will be established with minimal patient safeguards, outdated or inefficient technology, and ill-prepared or insufficient staff. Further, competition from these suites would reduce inpatient angiographic volume and experience as well as negatively impacting the finances of nearby hospitals. The main argument advanced by detractors of physician ownership has been that the profit motive may result in unnecessary testing or procedures and ?cherry picking? the less complicated and insured patient.

Accordingly, the Clinical Practice Council of the Society for Vascular Surgery (SVS) requested that a white paper be written to provide guidelines on the establishment and function of outpatient endovascular suites. However, there was a considerable debate as to what should be included in this white paper with some even suggesting that these outpatient suites should not be supported. Consequently, the Council requested the authors to initiate debate on the subject. Eventually the SVS may have sufficient information from its membership to produce a definitive statement as to the role and function of these outpatient facilities. Therefore, this editorial is based on the opinion of the authors. It is not a product of a systematic review nor is it a comprehensive analysis of the subject. Neither is it a product of the Society for Vascular Surgery. Readers are encouraged to consider the information presented, evaluate other material and reach their own conclusions. The authors would appreciate feedback in the form of letters to the editor of "Vascular Specialist" or directly to the authors. Their emails accompany this editorial.

What we think!

Diagnostic arteriography, venography, venous ablation, balloon angioplasty, atherectomy, vena caval filters, filter extraction, and stenting can all be performed in an outpatient setting and have been shown to be safe provided that standard quality controls are in place.

Compared to in-hospital centers, these free-standing outpatient suites may offer more efficient clinical operations, saving time and money for the patient, the surgeon and the insurance provider. Patients could benefit from the convenience and consistency of on-time appointments, convenient locations, shorter wait times, easier scheduling, onsite parking and less intimidating surroundings. The location and space allotted to the suite will vary. However, every effort should be made to assure that these positive attributes of outpatient endovascular suites are incorporated. The insurance carrier may benefit by reimbursing the center less than if the procedures were performed in a hospital. This would then result in lower co-pay for the patient and reduce overall premiums and the cost of healthcare. Vascular surgeons would have the convenience of working in a familiar facility usually in proximity to their clinic or private office. Importantly, they would work in an environment where they have direct control over safety, quality, personnel, equipment and cost.

Some endovascular suites are directly affiliated and attached to hospitals whereas others are independent and located at variable distances from hospitals or emergency facilities. Irrespective of ownership or location considerations, the prime concern for the vascular surgeon should be patient safety. Accordingly, special considerations may be required when these procedures are performed in locations at a distance from hospitals. Foremost, only procedures and technology proven to be safely performed as an outpatient should be considered for that setting. Newer technologies and procedures should probably not be utilized until their safety has been established. For example, although diagnostic carotid arteriography may be safely performed, stenting of carotid lesions probably should not be performed in these outpatient facilities at this time.

Procedures to prevent wrong side interventions, incorrect medication administration and other safety precautions, standard in hospital environments, must also be followed. Timely production of complete procedure reports and hard copy (digital or other media) of the images is strongly encouraged since these will most often be reviewed offsite.

Nowadays "cloud" storage of data may allow easy access to images although privacy concerns must be safeguarded. Tracking of complications such as hematoma formation, allergic reactions and other quality parameters such as contrast dosages, fluoroscopy time etc., should be performed on a regular basis.

In many states, complications must be reported to the relevant State Department of Health usually within 48 hours for their review. Most importantly, the endovascular suite should have in place a plan to deal with emergencies that may arise during or soon after a procedure such as cardio-pulmonary arrest, retroperitoneal bleeding, access site bleeding, false aneurysm, anaphylaxis etc. Standard care should incorporate having ACLS certified personnel present at all times with the ability to perform aggressive CPR including intubation, cardiac defibrillation etc.

Physicians administering or supervising moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia should have appropriate education and training. Since hospitalization may sometimes be necessary, a protocol for transfer of the patient to the nearest hospital should also be in place.

Transfer mechanisms should include the ability to offer advanced life support. A written agreement with the receiving hospital should be mandatory. If anesthesia services are provided arrangements regarding the role of these ancillary personnel should be contracted.

High quality X-ray imaging is a prerequisite for evaluation of vascular anatomy and the safe placement of catheters, stents and other intravascular devices. The goal should be to provide the best quality device with the least radiation exposure to staff and patients. Fixed overhead units are considered to offer better images, expedited procedures and potentially less radiation but newer portable units do provide acceptable images for most applications.

However, the choice of image intensifier (fixed overhead or portable) will often be based on space as well as cost considerations. No matter which device is chosen, standard radiation safety precautions should be followed (radiation badges, monthly dosimetry reports, lead lined rooms, etc).Every attempt should be made to assure that the quality and safety of the suite is equal, or superior ,to the in-hospital facility where the surgeon would otherwise be performing these procedures.

Disposable equipment (catheters, contrast agents, angioplasty balloons etc.) should all be present in sufficient quantity and quality to allow the procedure to be performed completely and safely. Strict inventory review must be done on a scheduled basis. There should be sufficient room to perform procedures from the neck, brachial, femoral or distal leg positions. Monitoring equipment including blood pressure, oxygenation, EKG etc should be present.

A regular maintenance program for all equipment must be in place. Satisfactory post-procedural areas should be available and staffed with protocols in place to reach the treating surgeon should an emergency occur. The treating surgeon must be available for a rapid response to unexpected complications that may be life or limb-threatening.

Standard precautions to protect patient confidentiality must be followed and all city, state or federal regulations governing these suites should be observed. Compliance with federal statutes such as the Anti-Kickback law and Stark law as well as individual State requirements must be in place

Physicians who own or lease these endovascular suites must assume an active role in managing the facility. This can result in increased productivity, quality and efficiency but can also result in real or perceived conflict of interest due to increased utilization and compensation.

However, the simplistic implication that physician ownership leads to increased utilization ignores the complexities involved in decision making that include multiple regulatory policies and clinical, non-financial, incentives. Irrespective, the vascular surgeon who receives remuneration for managing or owning the suite should fully disclose this arrangement to the patient or involved parties. Such relationships should be fully transparent to all stakeholders and comply with Federal and State statutes. Ultimately, the patient should be given the opportunity to decide on the location where they are to have the planned procedure.

In summary, then, we believe that many endovascular procedures can be safely performed in outpatient endovascular suites and that this can result in benefits for patient and surgeon. The author's support SVS members' use of these suites, regardless of ownership, as long as potential conflicts of interest are fully disclosed to the patient and provided that high quality care is provided safely and cost effectively.

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