Alberto Muñoz tells Vascular News about his 35 years in vascular surgery, including his involvement in the World Federation of Vascular Societies, and discusses the landmark advances made in these decades and what he hopes is yet to come.
Why did you choose medicine as a career and how did you decide to become a vascular surgeon?
My father was a born on his family farm near a town called Libano (Tolima), where he grew up. From elementary to high school he was a very dedicated student and he was accepted to medical school at the National University of Colombia in Bogotá, the capital city. He dedicated his life to his patients as a specialist in Internal and Pulmonary Medicine. His main area of interest was tuberculosis (TB) and based on his research he started short-term ambulatory treatment of tuberculosis in our country. This changed the history of TB treatment in Colombia. His approach to patients and medicine influenced me to go to medical school. At the end of the fourth year, December 1997, I went for a vacation to a small, remote village at the Colombian Pacific Ocean. There was no physician in the village, only a nurse and a small nursery with some sterile instruments, medicines, and sutures. The 1st of January, just after celebrating the new year, I was sleeping and was called because a fight had happened and there where four patients with stab wound injuries in the extremities, that I had to treat. One of the patients had a pulsatile bleeding from his radial artery and the nurse was compressing it when I arrived. This was my first vascular intervention, an arterial ligation. The four patients did well with the apprentice surgeon sutures.
Who have been your career mentors and what did you learn from them?
I studied General Surgery at Javeriana University in a programme with the National Cancer Institute in Bogotá. There I met my first mentor in Vascular Surgery, Professor Jorge Ulloa Dominguez, from whom I learned lymphography, lymphoedema management, vascular tumours, malformations and varicose vein treatment. I also met another of my mentors, Professor Alvaro Caro, who gave me my first job, as an instructor of Surgery at Samaritana University Hospital, a very active trauma centre, once I finished my residency. With him, I learned trauma. I remember treating subclavian, carotid, aortic, retro-hepatic vena cava, extremity vascular trauma, and emergency surgery. There was not a residency programme for Vascular Surgery in Colombia at that time, so I decided to train in Cardiovascular Surgery at Hospital Militar Central in Bogotá. My mentors Gilberto Clavijo and Tulio Parra, taught me great vessel reconstruction and bypass. The service performed cardiac, vascular, thoracic, transplant and vascular surgery. In 1990 I had the privilege of participating at the UCLA Symposium, a full week course with an outstanding review of all vascular surgery. There I met Dr Wesley Moore and many top vascular surgeons who inspired me. Dr Moore, through this course and his book, was one of my mentors.
In 1993, I met Dr Eugene Strandness from the University of Washington in Seattle, who visited us twice in Colombia, helped us to start our vascular laboratory and gave us the strength to start duplex scanning. Dr Herbert Dardik, who also visited us twice and received me at Englewood, mentored me in complex lower extremities revascularisation.
After the endovascular revolution I felt the need to receive training. In 2009, through a very altruistic and charismatic Canadian from Toronto, Bill Blair, I was introduced to Tom Forbes, Guy de Rose and Kirk Lawlor at the University of Western Ontario in London, receiving the Vicky Blair Fellowship and performing a one-year Clinical Fellowship, where I participated in more than 350 Aortic Surgeries, 60% endovascular. Working with them changed my career. Dr de Rose impressed me for being a very talented surgeon.
How have you seen the field of vascular surgery change and develop in your 35 years as a surgeon?
It is amazing how it has changed since I started my surgical practice, from pulse palpation and angiography to duplex scanning, CTA, MRA, and digital subtraction angiography, and from open surgery to minimally invasive endovascular or hybrid interventions. The two most outstanding advances in vascular surgery during these 35 years have been non-invasive vascular diagnosis and endovascular interventions. Also, evidence-based medicine and the controlled randomised trial in Europe and the USA for carotid artery disease treatment, EVAR trials, BASIL trial and many others.
What is the state of vascular surgery in Latin America as compared to the rest of the world?
Today, vascular surgery is an independent specialty and 16 countries have a Society for Vascular Surgery. The Latin American Association for Vascular Surgery (ALCVA) is a Federation that includes all these national vascular societies and is a member of the World Federation of Vascular Societies. Latin-America vascular surgery has been growing parallel to the rest of the world and has a place in the history of vascular surgery. Significant contributions, from Pirovano, a friend of Alexis Carrel, in Argentina performed the reconstruction of iliac and femoral artery aneurysm with a cadaveric homograft in 1910, lumbar sympathectomy (Diez, 1924), closure of patent ductus arteriosus (Goñi Moreno, 1937), correction of aortic coarctation (Albanese 1939), carotid reconstruction (Carrea Molins 1951), venous femorofemoral bypass (Palma Esperon, 1958) to Parodi’s endovascular repair of abdominal aortic aneurysm (1990), have been made by Latin American surgeons. From its early days, vascular surgery in Latin America has been in constant development and evolution. Patients with different vascular pathologies, including trauma, have received treatment with endarterectomy, aneurysm repair, and bypass surgery techniques. The treatment of venous disease and the practice of ultrasonography and endovascular surgery are also currently performed by vascular surgeons.
Education in vascular surgery varies considerably across Latin American countries. Some have a four-year training programme that includes two years of general surgery and two years of vascular surgery. Others have training in general surgery and cardiovascular surgery. And in other countries, a complete training and certification in general surgery and then two years of vascular surgery. The number of physicians dedicated to vascular care has increased rapidly over the past two decades. The development of endovascular surgery in the past 20 years has also created the need for training. This demand has been met since it is now part of vascular surgery training. The practice of vascular surgery is similar in Latin America to the rest of the world, but resources for practice may vary in the different countries.
Which areas have room for change and improvement? How can this be achieved?
We need more technology and resources in public hospitals. Also better organisation of the health system in order to centralise patients with vascular disease. It is very important to maintain training in open surgery. Many of the young trained vascular surgeons are better trained in endovascular surgery and need to be good at both to offer each patient the best treatment.
There is a shortage of vascular surgeons in many countries. One solution is to offer an integrated programme (0–5) in more countries, and to ensure that the title of vascular surgeons trained abroad is recognised in order for them to be accepted to practice, since there are countries where general surgery training is required.
You are the President of the World Federation of Vascular Societies— why is an organisation like this important?
The WFVS was established by the major vascular societies of the world to provide a forum for the international exchange of educational, political, and scientific issues related to the diagnosis, treatment, and prevention of vascular diseases. Its member societies, representing the major geographic regions of the world are: Society for Vascular Surgery (SVS) representing North America, European Society for Vascular Surgery (ESVS) representing Europe, Australian and New Zealand Society for Vascular Surgery (ANZSVS) representing Australia and New Zealand, Japanese Society for Vascular Surgery (JVS) representing Japan, Vascular Society of Southern Africa (VASSA) representing Southern Africa, Vascular Society of India (VSI) representing India and the Latin American Association for Vascular Surgery and Angiology (ALCVA) representing Latin America.
A Symposium of the World Federation is held annually at the same time and place as the congress of one of the member societies. This is important since the diagnosis and treatment of patients with vascular disease are in constant evolution. New technologies appear and we need to be aware of them and train ourselves in order to take good care of our patients. The idea is that relevant topics of vascular surgery be exchanged between the various World Vascular Societies in order to provide the best possible management in every corner of the world.
What have you achieved in your term as President and what are your hopes for the future of the organisation?
I have represented the WFVS in different meetings like the SVS Boston, ESVS Valencia, VASA Capetown, Charing Cross London, Padova International Congress, Panamerican Rio de Janeiro, Ecuador Society Quito, Argentinian College of Cardiovascular Surgery (CACCV) Buenos Aires and continue the work of my predecessors in organising the annual meeting of the WFVS, Latin-American Association for Vascular Surgery (ALCVA) and Uruguayan Society for Vascular and Endovascular Surgery (SUCIVE) that was held in Montevideo, Uruguay from 5–8 December, with great success. Collaborating with the co-editors and authors of the Global Vascular Guidelines. Also collaborating on different projects of the WFVS, such as the Global Amputation, that we have been working on under the leadership of Professor Martin Björck from Upsala, Sweden. And just starting the project of writing the Guidelines for the Management of Carotid Body Tumour. I hope the WFVS will continue to fulfil its mission of integrating vascular surgeons around the world and that the WFVS annual meetings generate more interest. Also, that it continues to develop projects that benefit the world population in the prevention and management of vascular disease.
What new vascular technology are you watching closely and why?
Technology is developing in such a fast way that I would have to mention many for the diagnosis and treatment of aortic, arterial, carotid and venous disease: fusion technology systems that are used even with a C-Arm or a cath-lab and allow endovascular 3D navigation at a low cost. Tomographic ultrasound is of great value for diagnosis and follow-up of different vascular diseases and treatments. Fenestrated and branched endografts for the treatment of complex aortic aneurysms and dissection of the ascending, arch, descending and thoracoabdominal aorta. New devices for the treatment of central venous obstruction and cryo-preserved human tissue grafts are among many other new technologies that I am watching closely, because they all represent very useful technologies that will benefit the quality of life of many patients and simplify complex treatments.
What is the most interesting paper or presentation that you have seen recently?
The new Global Vascular Guidelines for the management of Chronic Limb Threatening Ischemia (CLTI) that will be published in the JVS and EJVS next year. They are the product of a big effort of the SVS, ESVS and WFVS: an international collaboration in which co-editors Micahel Conte (SVS), Phillippe Kolh (ESVS) and Andrew Bradbury (WFVS) and 58 authors from around the world and different disciplines involved in the diagnosis and management of CLTI have written a document on the clinical classification and staging, anatomical staging and evidence-based treatment of an individual patient with CLTI. It also has recommendations to orient future research in CLTI.
You have had the opportunity to train in many countries—how did you benefit from these experiences?
I have received the benefit of learning from many vascular surgeons from different countries and cities the art, science and practice of the speciality. Learning from them what is not written, through observing surgeries, interventions or by comments and explanations kindly received. Also by observing the differences between patients’ psychology, anatomy and pathology that may vary from one country to another.
What are your interests outside of medicine?
Spending time with my family and travelling for vacation in Colombia or around the world. Reading a good book. Playing basketball or watching the NBA. Waterskiing.
2017–2018 President of the World Federation of Vascular Societies and Councillor for Latin America
2014–2017 Secretary General of the World Federation of Vascular Societies and Councillor for Latin America
2012–2014 President of the Latin American Association for Vascular Surgery and Angiology
2002–2004 President of the Colombian Association for Vascular Surgery and Angiology
Professional career (selected)
2016–present Chief of Vascular Surgery at the Hospital Universitario Nacional de Colombia in Bogota, Colombia
2010–present Vascular and Endovascular Surgeon at the Hospital Universitario Fundacion Santafe de Bogota in Bogota, Colombia
1993–present Vascular Surgeon at the Asociación Colombiana de Diabetes in Bogota, Colombia
1992–present Director and Founder of the Clinica Vascular De Bogota in Bogota, Colombia
2008–present Associate Professor of Surgery at the Universidad Nacional de Colombia in Bogota, Colombia
2005–2008 Director of the Graduate Program of Vascular Surgery and Angiology at the Universidad El Bosque in Bogota, Colombia
2009–2010 Clinical Fellow at the University of Western Ontario in London, Canada
2005 Degree in Vascular Surgery and Angiology at the Universidad Militar Nueva Granada-Hospital Militar Central in Bogota, Colombia
1988–1990 Degree in Cardiovascular Surgery at the Universidad Militar Nueva Granada-Hospital Militar Central in Bogota, Colombia
1981–1984 Specialist degree in General Surgery at the Universidad Javeriana-Instituto Nacional de Cancerología, Bogota, Colombia
1974–1980 Medical Doctor and Surgeon at the Colegio Mayor de Nuestra Señora Rosario in Bogota, Colombia