Peter Schneider (University of California San Francisco, San Francisco, USA) speaks to Vascular News about his life and career. Trained during the era of open surgery only, Schneider saw the benefits of endovascular intervention early on, writing Endovascular Skills in the early 1990s and unlocking “one of the most fun aspects” of his career so far, with doctors from around the world sharing with him the importance of the book in their catheter experience. Looking at the field of vascular surgery more widely, he opines that the “next wave” of advancement is imminent, pointing towards technologies that he believes will enable more personalised care of patients—and considers some of the major challenges that need to be addressed.
Why did you choose to specialise in vascular surgery?
Work on the vascular system caught my attention because of the unique combination of multifaceted, multiorgan system care in patients with little margin for error. Vascular surgery gives the opportunity to provide full spectrum care, to make long-term relationships, and to make a difference in the lives of the most vulnerable. The goals are practical, dilemmas are intellectually stimulating, the procedures are anatomically based, aesthetically pleasing, and technically challenging, and, there are numerous opportunities for innovation. My training was in the era of open surgery only. The potential that catheter-based techniques could be a natural complement to what we offer with open reconstruction really caught my attention and convinced me in the late 1980s that surgeons needed to be able to include endovascular work in daily practice.
Who were your career mentors and what was the best advice that they gave you?
So many important people contributed to my knowledge base and advancement, that I cannot name them all here. Nevertheless, there were several standouts from my time in San Francisco and my early career in Los Angeles. These include; Bill Krupski (take the time to mentor trainees), Linda Reilly (thinking through a challenging clinical scenario), Ron Stoney (complex open aortic work), George Andros (challenge the status quo when it is important), Jerry Goldstone (make connections across specialties and across the world), Doug Gray (cutting-edge work can be performed in a community hospital setting), Joe Rapp (patience), Leo Dulawa (have fun every day), and Bob Harris (best all-around technical surgeon with whom I have worked), and Eugene Bernstein (understand the complex well enough to make it simple).
What have been some of the most important developments in vascular surgery over the course of your career so far?
There has been substantial evolution in every aspect of the vascular care we offer over the past three decades. Improvements in medical management, the care of aneurysm disease, venous disease, arterial occlusive disease throughout the body, and the prevention of limb loss have occurred. I believe that we are on the precipice of the next major acceleration in advancements. The first was the ability to get patients with many comorbidities through major open surgeries. The second was the ability to do complex reconstructions using endovascular means. I believe that the next wave of advancement is upon us and will include the broad use of biologic therapies, the incorporation of AI, introduction of genomics, and the use of sensors and digital health to further transform our field and to eventually result in personalised medical and surgical care for our vascular patients.
What are the biggest challenges currently facing vascular surgery?
1) One of the wonderful and collegial things about vascular surgery is about how small and personal it is and how one person can have an idea that will make a difference in practice. However, at the same time our small workforce is a major disadvantage, especially with the avalanche of vascular disease upon us resulting from the demographics of the present era. 2) The multi-organ system nature of vascular care also dictates that we must stay at the forefront of multiple processes affecting multiple organs and their corresponding medical disciplines. 3) Another major challenge is that the awareness and education in vascular disease, and advocacy for vascular patients has trailed other fields. Our small size, the relatively recent nature of advances in care in this area, and the fact that we care for patients who do not have a voice in the various socioeconomic systems in which we work contribute to this challenge.
How did the treatment offered to vascular patients at Kaiser Permanente change over the 24-year period you were there?
When I arrived in Hawaii, the Kaiser system (a large hospital system in the USA) did not have a vascular programme. We established a multidisciplinary diabetic limb treatment programme which initiated in January of 1995 and was responsible for evaluating every diabetic within our catchment area who developed a foot lesion and resulted in a 50% decrease in amputation within a year. We started an accredited vascular diagnostic lab, registries for aneurysm and carotid disease, oversaw the installation of an endovascular operating room in 2003, established an endovascular aneurysm repair (EVAR) programme for ruptured abdominal aortic aneurysm (AAA), and a robust clinical research programme. We used Telehealth regularly and sent staff to other islands to see patients given the broad geography of the Hawaiian islands. When closure devices became approved in the early 2000s, we began to do outpatient endovascular procedures with enough confidence and safety that we were able to send patients home to the other islands on the same day of the procedure.
The thing of which I am the proudest is that between 1999 and 2011, we had a senior endovascular fellowship. This permitted trained vascular surgeons who had the content knowledge, the practice and the open experience to perform endovascular techniques with us for three months or more and then return to their respective practices. We trained 40 physicians in endovascular care.
You have served as national principal investigator for numerous clinical trials. Which of these trials do you think has had the most significant impact on vascular surgery?
We were able to enrol patients in numerous clinical trials even though we were in an isolated setting in a community hospital. Part of the advantage of our site was that we were able to include many patients who were considered underrepresented minorities. The trials that I felt were most significant included IN.PACT SFA and ROADSTER 2. IN.PACT SFA was a landmark femoral popliteal drug-coated balloon (DCB) randomised controlled trial (RCT) study that immediately established a standard for ‘best in class’ which continues today, more than 10 years later. The other study of which I am quite proud is ROADSTER 2. In this prospective, neurologically adjudicated, US Food and Drug Administration (FDA)-mandated study of transcarotid artery revascularisation (TCAR), the majority of cases were performed by new users, as opposed to previous carotid stent trials which required substantial experience of the operating physicians. The stroke and death risk in ROADSTER 2 was quite low and I believe also established a standard which subsequent carotid trials aimed to meet.
Could you tell us about Endovascular Skills?
I wrote Endovascular Skills in the early 1990s, partly out of concern that it was nearly impossible for practicing surgeons and vascular trainees to receive endovascular training. In an unanticipated manner, this endeavor turned out to be one of the most fun aspects of my career as doctors from around the USA and around the world have often approached me to mention that they used the texbook as a guide when they started their catheter experience.
When I started working on the book, I was finishing fellowship. I had a strong interest in catheter-based techniques, and I could see that this approach would gradually improve and become an important part of what we could offer our patients. I started to put together resources including notes from cases, from the materials and methods of journal articles and ideas from conferences. In the first couple of years of my career I continued to build on this. I would frequently hear that there was a lack of resources to help with the building phase of understanding and planning and being aware of what the specific choices were for endovascular approaches. Endovascular Skills became a single-author book in the mid 1990s and it is currently in its fourth edition. I have added to it over the years as the technologies have become more sophisticated and more devices have become available. It is intended to be relatively conversational and algorithmic and contains a lot of simple drawings that assist the reader in conceptualising where the procedure is going.
My hope was that by putting this together, it would accelerate the progress of others. As a consequence, I have met people from all over the world who have used the text as a fellow or some early time frame of their careers and who benefited from it.
What are some of your current research interests?
I continue to be highly interested in the challenges of lower extremity salvage and also the safe reconstruction of carotid bifurcation disease. In addition, I believe that calcification has evolved over the years, has become endemic and extensive, and that there is tremendous opportunity for improvement in the prevention of calcification and in the management of it once it occurs. Calcification defies TASC classification, is across organ systems, and makes both open and endovascular reconstruction more difficult. I see this as an area ripe for research and development in the coming years. In addition, during lower extremity revascularisation, I believe that there is likely substantial embolisation occurring at a subclinical level and may be causing long-term harm.
Could you outline one of your most memorable cases?
We have all had many memorable cases. We take our complications personally. It is nice to recall a time when on-the-spot thinking or perhaps luck helped to salvage an extreme situation. In the late 1990s, before we had the availability of EVAR, I operated on a ruptured aortic aneurysm. The patient and no detectable blood pressure and prior to the repair, I floated an aortic occlusion balloon under fluoroscopy. Upon balloon inflation, the patient immediately stabilized, allowing us to make an abdominal incision and get control of the aorta and do the repair. I believe the patient would have died if the classic open repair had been performed without prior balloon control. This patient was not recognised by me at the time of the emergency, however turned out to be one of my children’s school teachers. Subsequently, there was a lot of talk about this in the community as the patient went through a variety of challenges on his way to recovery. The patient subsequently quit smoking, finished out a career as a school teacher, and became a writer. This is why we do what we do. It was such a great reminder.
What advice would you give to someone looking to start a career in medicine?
The ability to do meaningful work, help those in need, develop your skills, push yourself toward lifelong learning, and have some important say over how the work should be done, are all key facets of a rewarding career. This is the possibility that you have with a career in medicine. It is a gift.
What are your hobbies and interests outside of medicine?
My lifelong passion outside of medicine is surfing and my personal relationships with
my family and friends.
