The future of vascular surgery: An Australasian perspective

Article Outline

• Abstract
• Current status of vascular surgery in Australasia
• Future challenges for vascular surgery in Australasia
• Research challenges for vascular surgery in Australasia
• Conclusion
• References
• Copyright

This article briefly outlines the current status of vascular surgery in Australia and New Zealand, reports on the future practice and research challenges as perceived by vascular surgeons in our two countries, and finally, explores how the current vascular surgical research efforts in Australasia map to those challenges.

Australia is a large island continent in the South Pacific with a small population of approximately 21 million persons. New Zealand is a small country of two islands, with a smaller population of approximately 4 million persons. Because the vascular surgery community in Australia and New Zealand is a small group numerically, and somewhat geographically remote, international interaction is essential, so we applaud the leadership of the World Federation of Vascular Societies for providing this forum for international interaction, and we would hope that long may it continue and prosper.

This article will briefly outline the current status of vascular surgery in Australia and New Zealand, report on the future practice and research challenges as perceived by vascular surgeons in our two countries, and finally, explore how the current vascular surgical research efforts in Australasia map to those challenges.

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Current status of vascular surgery in Australasia 

Australian and New Zealand vascular surgeons have long had a reputation for excellence and innovation and for being world travellers in their quest for learning, to acquire technical and research skills, and to share their surgical expertise. This is perhaps no better exemplified than in the last decade and a half during the endovascular revolution when Michael Lawrence-Brown, James May, Geoff White, and John Anderson have been at the forefront of developments in endovascular aortic repair. The early history of vascular surgery in Australia and New Zealand has been previously documented.¹, ², ³, ⁴ Significant changes have occurred in Australasian vascular surgery since the latter part of the 1990s. These are summarized in Table I.

Table I. Significant changes in the recent history of Australasian vascular surgery

ANZ, Australian and New Zealand; ISCVS, International Society of Cardiovascular Surgeons; FRACS, Fellow of the Royal Australian College of Surgeons; RACS, Royal Australian College of Surgeons; TGA, Therapeutic Goods and Administration; ANZSVS, Australian and New Zealand Society for Vascular Surgery.

In 1997 an independent Board of Vascular Surgery, separate from General Surgery, was established within the Royal Australasian College of Surgeons (RACS) to oversee vascular surgery training in Australasia. In the same year the first FRACS (Vasc) examination was conducted. An independent Board of Vascular Surgery has served the profession well and has allowed vascular surgery training and curriculum changes to evolve rapidly and proactively as alternative therapies and training needs have emerged. This has been no more evident than in the area of endovascular therapies. This flexibility saw the establishment of a direct RACS Vascular Surgery training program in 2001, without the need for a RACS General Surgery Fellowship. The comprehensive nature of the current RACS Vascular Surgery training program and examination process compared with other countries is evident in the 2007 publication by Cronenwett and Liapis⁵ where they surveyed vascular surgery training and certification internationally.

Currently in Australia and New Zealand, 151 vascular surgeons are Fellows of the Royal Australian College of Surgeons (FRACS, Vasc), 138 in Australia and 13 in New Zealand. In addition, a number of general and vascular surgeons are in rural and regional practice, particularly in New Zealand. In 2008, 48 vascular surgery trainees are at various stages of the 5-year RACS Vascular Surgery and Education Training program.

Vascular surgery in Australasia remains an attractive career path, with the number of applications for training positions far exceeding the number of available training positions in 2008. Approximately seven trainees have graduated each year since 2000 compared with 1985, when there were only two graduates from the first iteration of the defined RACS Vascular Surgery training subspecialty, which at that time consisted of 2 years of additional training in vascular surgery after the completion of a 4-year RACS General Surgery training program.

A Conjoint Committee for the Recognition of Training in Peripheral Endovascular Therapy was established in 2006.⁶ The Conjoint Committee is constituted by three parent bodies, the RACS, the Royal Australasian College of Physicians (RACP), and the Royal Australian and New Zealand College of Radiologists (RANZCR). The parent bodies have delegated to the Conjoint Committee powers to formulate training guidelines in peripheral endovascular therapy and to assess the training of persons seeking recognition of their training in this area. Training in peripheral endovascular therapy is assessed by the Conjoint Committee, usually in the context of the Specialist Advanced Training Programme of the RACS, RACP, or RANZCR. Recognition of satisfactory training is given after the successful completion of Specialist Advanced Training.

A process for the recognition of prior training and experience (Grandfathering Process), with a sunset clause, has also been introduced with the establishment of this Conjoint Committee.

Training requirements in peripheral endovascular therapy demand a minimum of 100 angiograms and 50 peripheral arterial interventions with the applicant as the primary proceduralist in 50% of cases. Carotid artery stenting requirements encompass completion of peripheral endovascular therapy training, knowledge of carotid stenting techniques and technology, competence in aortic arch angiography, the performance of 25 carotid artery stenting procedures as the primary proceduralist, and a preparedness to be involved in peer review outcome audit of results. The Conjoint Committee will shortly consider guidelines for the performance of complicated endografting, which will include thoracic endovascular aneurysm repair (TEVAR) and branched and fenestrated aortic endografting.

In 2008 it has been proposed that one of the conditions of membership of the Australian and New Zealand Society for Vascular Surgery (ANZSVS) should be participation in a Society-approved audit. This has been a requirement for membership of the New Zealand Vascular Society for many years.⁷

A trend has emerged in recent years toward greater government involvement and regulation of the practice of surgery, including vascular surgery, especially in Australia. Examples of this include the Medical Services Advisory Committee (MSAC) process for the evaluation of new technologies,⁸ a new Therapeutic Goods and Administration (TGA) regulatory framework for medical devices,⁹ and most recently, the introduction of Australian Federal Government Accreditation for Diagnostic Imaging.¹⁰

The MSAC process for evaluation of new technologies, which was established in 1998, aims to ensure that new and existing medical procedures attracting Medicare Benefits are supported by evidence of their safety, clinical effectiveness, and cost-effectiveness.⁸ New technologies are not funded by Medicare Benefits or private health fund reimbursement unless approved under this process. At this stage, many of the newer endovenous technologies remain unfunded, pending review under the process.

In 2007 a new TGA regulatory framework for medical devices became effective⁹ that has made it more onerous and expensive for companies to introduce new technologies and to supply the same extensive range of devices and goods that was available in the past. Already, as a consequence of these changes, many valuable but low-volume usage items are no longer available to the surgical community because it has proven economically unviable for companies to provide as extensive a range of products. Australian vascular surgeons have concerns that this new regulatory environment may stifle innovation and limit their early access to emerging technologies.

The Australian Government Accreditation for Diagnostic Imaging¹⁰ commenced in 2008. Under this scheme, all diagnostic imaging practices providing diagnostic imaging services will need to be accredited by an approved accreditation provider in order for Medicare Benefits to be payable for the services they provide. This will include vascular surgeons performing diagnostic imaging and endovascular interventions.

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Future challenges for vascular surgery in Australasia 

In preparation for this presentation, I conducted an e-mail survey of the vascular surgery community in Australasia seeking their views regarding:

Table II. The top challenges for vascular surgery in Australasia during the next 10 to 20 years as reported by Australasian vascular surgeons

•Workforce/manpower/training

•Endovascularskills/endovascularsuites/openskills

•Maintainingprimacyasthevasculardiseasespecialist

•BurdenofDisease

•AgingPopulation

•Epidemicofobesity,diabetes,renalfailure

•Funding/CostsGovernmentintrusion

•Achievingnationalaudit

•Thefutureofacademicsurgery

Vascular surgical workforce issues, training issues, maintaining primacy as the vascular disease specialist, and dealing with an increasing burden of vascular disease brought about by an ageing population in the midst of an epidemic of obesity, diabetes mellitus, and renal failure are the key concerns for Australasian vascular surgeons. They are also concerned about the availability of adequate funding and resources to deal with this burden of disease, and about the potential for increasing government intrusion and regulation of vascular surgeons' daily practice.

Australia's population, like that of many Western countries, is ageing as the baby boomer population bubble moves through. Between now and 2047, it is projected that the number of Australians of traditional working age (15 to 64 years) will rise by about one-fifth, older people (65 to 84 years) will more than double, and the very old (≥85 years) will more than quadruple.¹¹ The profile of the health workforce also continues to age: The proportion of those aged ≥55 years was 16% in 2006 compared with 12% in 2001.¹²

Although Australia is one of the healthiest nations in the world, with an average life expectancy of 81.4 years now second only to Japan,¹² Australians are fatter than they have ever been before. The prevalence of overweight and obesity (body mass index >25.0 kg/m², or waist circumference >80 cm for women or >94 cm for men) in Australian adults is approaching 60% for both sexes and has more than doubled in the past 25 years.¹³

Diabetes mellitus is on the rise in Australia, as it is across the world, and according to estimates from the Australian Diabetes, Obesity and Lifestyle Study, in 1999-2000 it affected nearly 900,000 Australians aged ≥25 years.¹⁴ Recent increases in the number of patients with diabetes have led to claims that it has now risen to epidemic proportions.¹⁵ The incidence of type 1 diabetes among Australian children aged ≤14 years is increasing by 3% a year, but the incidence in older children and adults seems to have stabilized, according to a new report.¹⁶

The number of new cases of treated end-stage kidney disease has tripled in the past 25 years, from 22 per 100,000 population in 1981 to 74 in 2006.¹² Between 2001 and 2005, there has been a 25% increase in the proportion of new cases of end-stage kidney disease caused by diabetes.¹⁷

Although coronary and other heart diseases are the leading cause of death in Australia, peripheral arterial diseases were the 12th and 14th ranked contributing causes of death for men and women, respectively, in Australia in 2005.¹² Cardiovascular diseases as a group contributed to 55% of all deaths in men and 60% of all deaths in women in 2005.¹²

Australia spent $1 in every $11 on health in 2005-2006, equalling $86.9 billion or 9.0% of the gross domestic product (GDP).¹² As a share of its GDP, Australia spent more in 2005 than the United Kingdom (8.3%), but much less than the United States (15.3%).¹² Australian government spending on health is projected to increase as a proportion of GDP from 3.8% in 2006-2007 to 7.3% in 2046-2047.¹¹

All these issues have an impact on vascular surgeons. There are concerns of a looming manpower crisis in vascular surgery in Australasia. Whether this eventuates remains to be seen. Unfortunately, workforce manpower planning is hazardous at best, and the data on which to base projected needs is often only a best guess and potentially subject to rapid change. The suggestion that there will be an ongoing increase in the number of patients with peripheral vascular diseases requiring treatment—but inadequate numbers of vascular surgeons to cope with the demand—has also been made in the United States.¹⁸ The manpower concern currently is more often raised in the context of delivery of emergency and after-hours vascular services rather than for elective services. Already many vascular surgeons have commented on an increasing acute and after-hours workload with older, sicker, and more complex patients.

The coexistence of a move towards government and Australian Medical Association–recommended safe working hours¹⁹ and a societal change in favor of better life–work balance amongst younger surgeons who balk at working intensive after-hours call schedules is already posing difficulties in providing sustainable acute vascular surgical services, even in major tertiary referral hospitals. This issue is even more evident in regional centers, where there may be only one or two vascular surgeons. The additional emerging problem, again most evident in regional centers, relates to the provision of emergency general surgical and trauma services. Subspecialty trained surgeons increasingly decline to participate in these on-call rosters, citing a lack of a general surgical qualification or adequate recent general surgical experience. This is a direct consequence of increasing surgical subspecialization, as demonstrated by direct vascular surgery training without the need for general surgery training. Restoring the balance in this regard is under consideration by the RACS Board of Vascular Surgery, with a proposal for a dual General and Vascular Surgery Fellowship comprising 4 years of general surgery training and 3 years of vascular surgery training with separate examinations in general surgery (year 5) and vascular surgery (year 7).

There are concerns, particularly among more senior vascular surgeons, about whether trainees are now adequately trained in major open vascular surgery. The greatest concern relates to open aortic surgery, because some centers in Australasia undertake up to ≥70% of abdominal aortic aneurysm (AAA) repairs by EVAR, and in most centers, TEVAR has become the treatment of choice for most thoracic aortic pathologies. Fellowships in open aortic surgery, after the completion of standard vascular surgery training, are being considered in some centers, such is the concern.

Conversely, although current trainees are generally well trained in endovascular techniques, there are concerns among more senior surgeons about how they can be retrained and adopt endovascular techniques into their practice. Debate is occurring about whether the vascular surgery service of the future can expect all individuals to be equally proficient in all aspects of vascular care. Some have suggested that a future vascular service might consist of a group of vascular clinicians who, much like what has occurred in cardiology practice, concentrate in selected areas; for example, open surgery, complex aortic surgery, basic or complex endovascular surgery, vascular imaging, and vascular medicine. Most recently, discussion has turned to the issues of how skills can be maintained, particularly for low-volume interventions, and how and how often recredentialing should occur. How to manage the failing or underperforming surgeon remains problematic.

Turf wars and concerns about maintaining primacy as the vascular disease specialist continue. Currently in Australasia, the turf wars vary from region to region, depending on local personnel and access to and availability of facilities. The battle with radiologists has mainly been about access to angiosuites in the public hospital system, where historically, the angiogsuite has been the domain of the radiology department. What is clear is that young vascular surgeons graduating from training programs and equipped with endovascular skills expect access to angiosuites and endovascular facilities as a matter of course, and they will not accept appointments at institutions where access to these facilities is not provided. This is no longer an issue in the private sector where vascular surgeons trained in endovascular techniques are readily credentialed and provided with access to the endovascular facilities they require. The current facilities challenge in Australasia is to populate vascular surgery operating theaters with state of the art hybrid operating endovascular suite facilities.

Radiologists are not currently considered a major threat in terms of primacy as the vascular disease specialist in Australasia. This is because at present, radiologists are not primary care physicians, do not have comprehensive training in vascular diseases, do not have hospital admitting rights, and rely on referrals from other practitioners. There are moves to change this, however.

Cardiologists are currently perceived as a greater threat to the established order because they have access to patients who have systemic atherosclerotic disease, they have access to facilities with their own cardiac catheterization laboratories, and they have high-level catheter skills. Prompted by the example of many cardiologists in the United States, a number of Australasian cardiologists have embarked on the endovascular treatment of peripheral, carotid, and renal artery disease in particular.

Australasian vascular surgeons currently believe that with their comprehensive training and their ability to offer the full range of open, endovascular and medical therapies, that they are well placed to maintain their principal role in the management of patients with vascular diseases. To ensure that this occurs and for vascular surgeons to maintain primacy and credibility in the field of vascular disease management, it will be important for vascular surgeons and the Australian and New Zealand Society for Vascular Surgery (ANZSVS) to develop a greater profile in the community and with the general practitioner referral base, to market and promote ourselves more widely in the community, to become more politically proactive, and to monitor and report on our results as part of a national audit or vascular registry. These are lessons that our US colleagues and the American Vascular Association have already taken on board.

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Research challenges for vascular surgery in Australasia 

The most important research questions listed by Australasian vascular surgeons for the next 10 to 20 years are summarized in Table III. These are not unique to Australasia and are probably generally reflective of the research issues that would be proposed worldwide. There is a clear desire for a better understanding of the basic biology of the broad spectrum of vascular pathologies, including atheroma, restenosis, AAA, and aortic dissection, in particular. The hope is that such knowledge might translate to alternative medical or gene therapies to prevent or ameliorate the progression of these disease processes before invasive intervention is required. In addition, better knowledge of the basic biology and factors that precipitate symptomatic events, such as plaque rupture, aneurysm progression and rupture, aortic dissection, and dissection expansion might allow better timed and targeted invasive interventions.

Table III. The main research questions relating to vascular surgery that Australasian vascular surgeons would like answered during the next 10 to 20 years

AAA, Abdominal aortic aneurysm; CAS, carotid artery stenting; CEA, carotid endarterectomy; EVAR, endovascular aneurysm repair; PAD, peripheral arterial disease; SFA, superficial femoral artery; TEVAR, thoracic endovascular aneurysm repair.

There is a desire to further refine selection criteria and follow-up protocols for EVAR. Australasian vascular surgeons, who have had access to most available endovascular devices, see an ongoing need for better devices, particularly for thoracic aortic interventions, where the currently available TEVAR devices have varying limitations in dealing with much of the anatomy confronted. There is a desire to better define the appropriate use of endovascular techniques for a variety of other indications, including claudication due to superficial femoral artery disease, carotid stenosis, aortic dissection, renal artery disease, and varicose veins. The yearning for smaller diameter and better functioning prosthetic grafts for peripheral arterial reconstruction and arteriovenous access creation remains unfulfilled. Similarly, the desire for alternative therapies for the non-reconstructible limb remains at the forefront of Australasian vascular surgeons' wish list.

When the current research being undertaken by Australasia's vascular surgeons is examined, the research activity maps quite closely with these unanswered questions. Australasia's vascular surgeons continue to push the boundaries of endovascular aortic repair for ever more complex disease, particularly of the thoracic and thoracoabdominal aorta, and for infrarenal aortic disease with complex iliac anatomy.²⁰, ²¹, ²², ²³, ²⁴ Australasia's surgeons are participating in device trials for acute thoracic aortic dissection,²⁵ and funding is being sought to establish a registry to monitor the outcomes of TEVAR for traumatic thoracic aortic tear. A number of groups have active research programs examining the prevalence, biology, and genetics of aortic and peripheral arterial diseases in an effort to define roles for screening and possible medical interventions.²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³², ³³, ³⁴, ³⁵, ³⁶, ³⁷

Recently, a helpful interactive model to predict outcomes of EVAR has been developed after analysis of the longitudinal Australian audit of EVAR.³⁸ This interactive model that is available for download can be used in day-to-day patient consulting for counselling and preoperative decision making. The model uses eight preoperative variables (aneurysm size, age, American Society of Anesthesiologists score, gender, creatinine, aortic neck angle, infrarenal neck diameter, and infrarenal neck length) to predict the likely outcomes of EVAR, including perioperative mortality, perioperative morbidity, medium-term survival and reintervention rates.³⁹ Five of the variables are available before any imaging and can be used to provide preliminary risk estimates. Funding has been sought to enable this model to be validated prospectively using a new cohort of Australasian EVAR patients.

A number of groups are active in peripheral artery disease research covering such as areas as medical therapy,⁴⁰ exercise therapy for claudication,⁴¹, ⁴², ⁴³ and brachytherapy to inhibit restenosis after femoral angioplasty.⁴⁴ There is a desire to establish a national database to accurately assess performance of femoral artery interventions (open, endovascular, and medical therapies) with outcomes to also include quality of life assessment in addition to the traditional hard end points of vessel patency and limb salvage rates.

The patient with critical limb ischemia who has exhausted reconstruction options because of lack of suitable conduit or because of the non-reconstructible pattern of their arterial disease remains a major challenge for vascular surgeons. Australasian vascular surgeons are involved in a number of research efforts that may offer hope in this area. A number of centers are involved in trials of angiogenesis for patients with severe non-reconstructible peripheral arterial disease.⁴⁵ Efforts continue to develop a tissue-engineered vascular graft, grown in the peritoneal cavity on silastic tubes, which could be used for arterial revascularization or as an arteriovenous access conduit.⁴⁶, ⁴⁷ This methodology has recently been used to grow myofibroblast-rich tubular structures and tissue capsules for use as autologous grafts for hollow, smooth muscle–walled visceral organs, including the bladder, uterus, and vas deferens.⁴⁸

Most recently, investigators in Sydney have commenced a program of hyperperfusion for peripheral artery disease patients facing amputation, the Hypertensive Extracorporeal Limb Perfusion (HELP) study.⁴⁹ An extracorporeal cardiac ventricle assist pump is used to increase the intra-arterial pressure in the femoral artery proximal to an occlusion. This increase in distal pressure is claimed to increase flow through collateral vessels. Preliminary results of this therapeutic trial are to be published shortly.

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Conclusion 

Vascular surgery in Australasia in 2008 is in a healthy state. At the same time, however, numerous issues regarding the vascular surgical workforce, training, credentialing, funding, government intrusion, and how vascular surgeons will retain their principal role in managing patients with vascular diseases loom large. An independent RACS Board of Vascular Surgery overseeing a vascular surgical training program that has been adaptable to the ever-changing field of vascular disease management has served the profession and our patients well. Coupled with a strong and proactive ANZSVS, and with research efforts well mapped to the relevant vascular research questions, we can look forward with confidence to dealing with the emerging issues and the increasing burden of vascular disease that is on the horizon.

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