DEBATE: Attenuation of IR Turf Vascular Surgeons and Cardiologists can Manage Massive GI Bleed, Trauma Intervention and Tumor Embolization Donald T. Baril, M.D. Assistant Professor, Division of Vascular Surgery University of Pittsburgh Medical Center

Donald T. Baril, MD DISCLOSURES I have no real or apparent conflicts of interest to report.

My opponent Anthony Venbrux, M.D. Professor of Radiology and Surgery, George Washington University Director of Interventional Radiology, George Washington University Hospital Chairperson of the Cardiovascular Radiology Council of the AHA US Army Commendation Medal for Meritorious Service to the Dept of Radiology Certificate of Merit from the American Roentgen Ray Society 103 indexed publications

My opponent

My opponent

When to call a surgeon

My opponent – The Surgeon? Professor of Radiology and Surgery Works in progress. The anal canal: distinction of internal hemorrhoids from small cancers by double-contrast barium enema examination. Thoeni RF, Venbrux AC. Radiology. 1982 Oct;145(1):17-9.

Have and will have the appropriate training Vascular Surgeons and Cardiologists can Manage Massive GI Bleed, Trauma Intervention and Tumor Embolization Vascular Surgeons and Cardiologists: Have and will have the appropriate training Have the appropriate endovascular skills Can offer all treatment modalities Are able to care for the patients

Proportion of training spent learning endovascular skills Vascular Surgeons and Cardiologists have and will have the appropriate training Proportion of training spent learning endovascular skills IC IR Integrated VS Traditional VS

InterventionalRadiology Vascular Surgeons and Cardiologists have and will have the appropriate training One year spent learning: Vascular interventions Genitourinary interventions PTCs PICCs/Ports G-Tubes J-tubes Percutaneous biopsies Draining pus TIPS Spinal interventions InterventionalRadiology

Vascular Surgeons and Cardiologists have the appropriate endovascular skills Type II Endoleaks Complex Type II Endoleak with IMA and Lumbars

Familiarity with microcatheter techniques Internal Iliac Angio Lumbar Type II Endoleak 5 Fr Catheter Renegade Micro cath Endoleak

Familiarity with microcatheter techniques 6 Fr Sheath In SMA IMA Endoleak Renegade Micro cath 5 Fr Catheter

Applicable skill set to other sites of embolization SMA Injection Gastroduodenal artery Hepatic artery Celiac Injection Splenic Artery

Vascular Surgeons and Cardiologists have the appropriate endovascular skills Technically similar to mesenteric interventions Relatively straightforward for experienced endovascular surgeons Familiar with pathology and possible complications

Vascular Surgeons and Cardiologists have familiarity with the anatomy and the pathology

Sometimes the hammer is perfect for the job “If the only tool you have is a hammer, you will see every problem as a nail.” Sometimes the hammer is perfect for the job

Sometimes you need more than just the hammer

Vascular Surgeons Can offer the entire range of therapies: Diagnostic angiography Therapeutic endovascular interventions Surgical control of hemorrhage Surgical reconstruction of injured vessels

All are great technicians Vascular Surgeons and Cardiologists have the ability and knowledge to care for these patients All are great technicians

The most important processes of care are Participation by the radiologist in patient follow-up is an integral part of percutaneous transcatheter embolization Close follow-up, with monitoring and management of the patient after the embolization procedure is appropriate for the radiologist The most important processes of care are 1) patient selection 2) performing the procedure 3) monitoring the patient

From the SIR

Training for the treatment of acute shock/trauma Interventional cardiology 3 years internal medicine 3 years cardiology 1 year interventional cardiology Traditional vascular surgery 5 years general surgery 2 years vascular surgery Integrated vascular surgery 5 years of vascular surgery

Training for the treatment of acute shock/trauma Interventional radiology 1 preliminary year 4 years general radiology 1 year interventional radiology

Training for the treatment of acute shock/trauma “The group has a great time……throughout the year the residents meet at several happy hours and other social functions.” “The residents are looking forward to spring and the start of the hospital softball league.”

Is the argument a moot point? Interventional Radiology Fellowship 2009 Match Statistics Certified Programs 83   Programs Filled 49% Certified Positions 212   Positions Filled 69%

Is the argument a moot point? Cardiology Fellowship 2009 Match Statistics Certified Programs 169   Programs Filled 98%  Certified Positions 718   Positions Filled 99%

Is the argument a moot point? Vascular Surgery Fellowship 2009 Match Statistics    Certified Programs 93 Programs Filled 81%  Certified Positions 121   Positions Filled 84% 

The Future 2010 Match 21 programs/23 positions Integrated Vascular Surgery Residency 2009 Match Results Certified programs 18 Programs filled 100% Number of applicants 152 Certified positions 18 2010 Match 21 programs/23 positions

Are the most appropriately trained to intervene on these patients Vascular Surgeons and Cardiologists can Manage Massive GI Bleed, Trauma Intervention and Tumor Embolization Vascular Surgeons: Are the most appropriately trained to intervene on these patients Offer the most complete set of skills to care for these patients Will be the interventionalists in the years to come who will perform these procedures

My real disclosure 6 months of vascular surgery fellowship

Just because you can doesn’t mean you should….

Appropriately trained Vascular Surgeons and Cardiologists can and should Manage Massive GI Bleed, Trauma Intervention and Tumor Embolization