As her term as the first female president of the European Society for Vascular Surgery comes to end, Alison Halliday reflects on what she has achieved and the future of the society. She also speaks to Vascular News about her current research, what is being done to encourage more women to choose the path of vascular surgery, as well as her interests outside of medicine.
What drew you to medicine and to vascular surgery in particular?
Many of my family did medicine, but I was better at English, languages and geography at school. I thought of archaeology and marine biology before deciding on medicine as the best overall education, with lots of future options. Surgery interested me right from my first attachment at Southampton and vascular surgery was my choice when I experienced the satisfaction of relieving the pain of ischaemia and preventing amputations, deaths and strokes. Most importantly, I also really enjoy talking to patients about their problems and trying to give them hope and a plan to make their lives better.
Who have been your career mentors and what lessons did you learn from them?
My husband, my teachers and professors and my colleagues—my husband believes, like me, that you can do whatever work you want to, my teachers inspired me at school and at work and my colleagues sometimes amaze me by their energy and kindness—it’s a great job!
What have been the proudest moments of your career?
Having my family at my graduation and my inaugural lecture as a professor, presenting the results of the first ACST trial and becoming president of the European Society for Vascular Surgery.
How have you seen the field develop during the course of your career?
Better medical treatments for vascular disease, especially statins—endovascular surgery—wider co-operation between specialities for treatment planning—changes in training from general and vascular surgery, to vascular surgery as a monospecialty.
What new vascular technology are you watching closely and why?
Carotid stents (of course!)—their development was put on hold by the early trial results comparing carotid endarterectomy (CEA) with stenting in symptomatic patients. Now many new ideas—mostly concentrating on reducing embolic potential from stenting—mean that the technology can be more widely applied in a safe way and I hope this will result in surgeons becoming more engaged in training for the appropriate use of stents.
What is the most interesting paper or presentation that you have seen recently?
Two new trials, the COMPASS and MANAGE studies, have shown new applications for the use of new oral anticoagulants (NOAC) in vascular surgery. COMPASS showed how cardiovascular death, stroke, or myocardial infarction could be reduced in patients with stable cardiovascular disease by combining NOAC and aspirin treatment. The MANAGE trial should change perioperative monitoring in future as it clearly showed that perioperative rises in troponin (even without symptoms) called MINS (myocardial injury after non-cardiac surgery) increase the risk of cardiovascular events and deaths; anticoagulation therapy for MINS can prevent major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism.
You are the principal investigator of two of the world’s largest trials in vascular surgery (ACST-1, ACST-2), how did these trials change practice and what questions remain unanswered?
ACST-1 clearly showed that, in patients with no recent symptoms from carotid stenosis which was suitable for surgery (usually 60–99%), carotid endarterectomy prevented future strokes, both disabling and fatal and non-disabling, for at least the next 10 years. These findings were clear (an absolute reduction of 6–7% for patients up to 75 years of age at trial entry) and were present even in those patients who were taking statins, in addition to other stroke prevention medicines.
ACST-2 is comparing carotid endarterectomy with stenting, in patients suitable for both procedures who have not had recent symptoms and has recruited over 80% of the planned 3,600 patients for this trial. Results are expected in 2021 and these results will, I hope, change future practice.
Unanswered questions always remain, but big questions in practice will, I hope, be addressed by these and future trials. Identifying patients at high stroke risk from their carotid disease, as with ischaemic heart disease, remains the biggest of these.
Much of your research is focused on stroke prevention, why is this an important topic and what more still needs to be done to improve patient outcomes?
Stroke is the largest cause of disability in many countries. Prevention depends on identifying the potential causes of stroke and carotid disease remains one of the most important and potentially preventable of these.
Safe surgery and intervention is of vital importance, but patient education on risks and benefits is also essential. Public awareness is improving, but the media need to be more effective in portraying the appropriate hazards of treatments such as statins and surgery, otherwise, the risk-adverse population with carotid disease will be exposed to greater risk by avoiding these treatments.
You are at the end of your term as President of the ESVS. What did you accomplish during your tenure and what are your hopes for the future of the society?
As the first woman to be elected president, other women in vascular surgery have, I hope, been encouraged to apply for office. My aims on election were to increase diversity in ESVS and we have made significant moves (including the appointment of a diversity ‘councillor’) to improve this; at ESVS I also created the Global Village—where every country is given free exhibition space to showcase their vascular services and their culture, as well as providing a networking space for the duration of the meeting. Finally, I still plan to study the Minimum Standards for Vascular Services in Europe—with my colleagues, I hope we can then demonstrate to European states the areas in which their future services may be usefully improved.
You are a committee member of the Gender Equality Advisory Group at Oxford University, and you work in a field that is largely dominated by men—what is being done to encourage more women to become vascular surgeons and what factors do you believe act as a deterrent?
There are now many more women trainees in Vascular Surgery and some more Consultants. Mentorship has improved, but there is no doubt that women have to work hard to keep both the home and the job running smoothly. Not many men take long-term paternity leave to care for children yet!
Perhaps the biggest barrier women face is making the long term choice to stay in surgery, even though their ability and patient commitment is not in doubt. One very positive factor is the “team” development, which is a better environment than the stand-alone consultant of the past—everyone appreciates good colleagues. The model of mixed Boards in business is clearly successful and companies show better financial results. A mixed vascular surgery consultant team should lead to better team relationships and open positive clinical development.
Could you tell us about one of your most memorable cases?
Lots are memorable! Perhaps one, where years ago a patient presented with crescendo TIAs and I was not on call, but was many miles away. I took three trains and two buses to reach the hospital and was really pleased to be able to operate successfully without further delay. This demonstrated the benefits of good colleague cover, which followed shortly after. On the same theme, whilst others were at a meeting, I successfully operated on a colleagues’ patient with a ruptured inflammatory AAA—the benefit of being on site!
What are your interests and hobbies outside of medicine?
I love walking, as well as reading and learning about science and literature outside medicine. Geology has become an interest since my son took up Explorations Geology and has just been awarded his MSc from Camborne School of Mines—the timescale of geology certainly puts life in context!
Professor of Vascular Surgery, University of Oxford
Hon Consultant Vascular Surgeon, Oxford University Hospitals NHS Trust
Senior Research Fellow, Green Templeton College, Oxford
- 1991–1993 Senior Lecturer & Honorary Consultant Surgeon, St Thomas’s Hospital, London
- 1992–1995 Hon Consultant in Vascular Surgery, St Mary’s Hospital, London
- 1993–2010 Consultant in Vascular & General Surgery, Epsom & St George’s Hospitals
- 2007–2010 Professor of Vascular Surgical Sciences, St George’s, University of London
- 2007–2012 Honorary Consultant Vascular Surgeon, Royal Free Hospital NHS Trust
- Principal Investigator of the world’s largest trials in Vascular Surgery (ACST-1, ACST-2)
- Leader of a research team and network of colleagues worldwide
- Supervisor, PhD research staff and students
- Establishment of a productive and long-term collaboration with the world-renowned Oxford Clinical Trial Service Unit, bringing statistical and trial design expertise to their large-scale clinical surgical trials
- Development of the world’s largest trial database of factors affecting durability of stroke prevention after carotid endarterectomy (>20,000 patient years)
- Development of International Stroke Research networks between Neurologists, Vascular Surgeons, Interventional Radiologists and Cardiologists in over 30 countries
- Substantial contribution to the body of knowledge in Vascular Surgery, Stroke Medicine and International Clinical Trials—helped develop European guidelines on the indications for Carotid Surgery
- Royal College of Surgeons, Hunterian Professorship
- University of Belgrade, Visiting Professor
- McMaster University, Hamilton, Canada – Annual Perioperative Lectureship, PHRI Anesthesiology, Perioperative Medicine and Surgery