1. 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

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

3. 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

4. My opponent

5. My opponent

6. When to call a surgeon

7. 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 Oct;145(1):17-9.

8. 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

9. 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

10. 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

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

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

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

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

15. 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

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

17. 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

18. Sometimes you need more than just the hammer

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

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

21. 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

22. From the SIR

23. 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

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

25. 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.”

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

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

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

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

30. 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

32. My real disclosure
6 months of vascular surgery fellowship

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

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