Excerpts from a Panel discussion moderated by Padma Shri & Dr BC Roy National Awardee Dr KK Aggarwal at the ongoing 4th Asia Pacific Vascular Intervention Course at The Oberoi, New Delhi
The Panelists included Dr Tyrone J Collins (Director, Cardiac Cath Lab, John Ochsner Heart and Vascular Institute, New Orleans USA), Dr Clifford J Buckley (Director, Div of Vascular Surgery, Texas A&M Health Sciences Center College of Medicine, Texas, USA), Dr Rajiv Lochan (Consultant Interventinol Cardiologist, Saudi German Hospitals Group, Dubai, UAE), Dr Saroj Das, Consultant Surgeon, The Hillingdon Hospital, UK) and Dr NN Khanna (Sr. Consultant Vascular Interventions, Indraprastha Apollo Hospitals and Course Chairman)
The instant reaction and anybody who is not aware or who is not a physician obviously will get biased with the opinion which was given in the episode of Satyamev Jayate that dealt with the issue of corruption in healthcare.
If one person has done something wrong, it cannot be generalized with everybody as bad profession. Secondly, it is also reflecting badly on all practitioners who are working faithfully, lawfully, taking care of the patients without any bias, keeping their income package separate from the interests of the patients, and most of the physicians do take care of their patients.
Doctors are not bad. There are some bad doctors just as there are bad engineers, bad attorneys. The consequences of being a bad doctor is more emotional than some of the other professions, that is why it receives so much press or so much notoriety when one doctor or single person does something that is wrong.
The percentage of bad doctors across the globe is very very small, less than 1%.
A major perception that gets medicine into trouble is that there is a difference between being a bad doctor and having a complication to a procedure that you do. But unfortunately the public wants a perfect result every time. But unfortunately we have complications with every procedure that we do and in a small number of cases, the patients sustain complications which are not really the fault of the surgeon, or the cardiologist or physicians taking care of them.
Most of the time, doctors do not have control over what the patients do to themselves before the doctors get to take care of them. Most of them smoke, many of them abuse their bodies in other ways they use drugs, use alcohol. This tends to increase the risk of any procedure
To err is human. Medical accident, medical adverse event is not medical negligence.
In vascular surgery, if 100 vascular interventions are done, the risk involved would be around 4-5%. In the hands of an experienced operator, you are looking at less than 1% mortality, if you are getting an open operation, probably you are looking at around 3 to 4% depends on what is wrong with the patient.
The United Kingdom has an audit program called PROM i.e. Patient Reported Outcome Measures. It evaluates what the patient feels when a particular intervention has been done for that. Has that improved the QOL of that patient? Is it justified that he should be spending so much of money or would the procedure be doing any good to them?. That is one part of the story.
The role of vascular surgery in patients with erectile dysfunction (ED) is still under investigation. There is a clear link between having a CAD or atherosclerotic disease and having ED. The problem is that is not well established that correcting or revascularizing is the only thing that needs to be done for this patient. Pudendal artery revascularization works, but it only works for some patients.
It is difficult to estimate the durability of some of the vascular interventions because people die of other existing comorbidity so you don’t really get a long term follow up on the effectiveness of that therapy.
Bone marrow transplant in chronic limb ischemia is a very labor intensive procedure and the outcome is still uncertain.
Leech therapy has been usedin India for more than 5000 years. It has been approved in the US as a medical device, as tools for healing skin grafts or restoring circulation. Leeches are used to remove blood pooled under skin grafts for burn patients, or to restore circulation in blocked veins by removing pooled blood.
Some important views from the Panelists about endovascular interventions
Dr Tyrone J Collins
Endovascular surgery therapy may be an alternative to surgical therapy.
Endovascular surgery is complementary to surgical therapy.
In patients with coronary artery disease, there is a high likelihood of having a vascular disease – about 30%.
Keep your BP under control.
Dr Clifford J Buckley
Risk factor modification is very important for all patients with vascular disease.
Aspirin and statins should be given to all patients.
Endovascular repair for abdominal aortic aneurysm has been one of the major improvements in endovascular care. It has changed it from a bigger operation to an overnight stay or 2–day stay in the hospital. The number of people who have complications with the device are very small. The benefit for the patient has been huge in terms of their ability to get back to their good quality of life.
Vaso-occlusive disease needs a good trial of intensive medical management if asymptomatic rather than any intervention.
HT should be treated, because HT poorly treated is responsible not only for CAD, but probably one of the largest causes of renal failure and the need for renal dialysis. The guidelines used to be 140/80, they are now down to 120/80 and I would say somewhere between 120/80 to 140/80 should be optimal.
Dr Rajiv Lochan
EV interventional area has vastly developed, it has expanded; surgery is now available from head to toe. Physicians should explore this option before saying no.
Diabetes is a common factor in these patients, so there has to be a strict control of sugar. A1c of 7 is ideal but 6.5 is reasonable because there can be complications with very tight control.
We need to maintain reasonable good control of LDL; atorvastatin 40 mg generally is used, but the dose depends on the level of LDL
Uterine artery embolization can be done in some patients after postpartum hemorrhage, the artery can be blocked without surgery. Earlier ligation of iliac artery was done.
Age is not a bar to endovascular intervention generally, it has to be dependent.
Dr Saroj Das
The oldest patient operated for a complex vascular procedure is Dr Michael DeBakey.
EV intervention has got no boundaries.
Lifestyle management remains the cornerstone of any thing that we do before and after any intervention.
This year, the prediction of diabetes for India is that half a billion people in India would have diabetes. This is going to contribute to the vascular load of patients. 20% of diabetic patients would have vascular disease.