Gustavo Oderich

Originally from Porto Alegre in the south of Brazil, Gustavo Oderich speaks to Vascular News about his journey to the Mayo Clinic in Minnesota, his career mentors who taught him the value of both open and endovascular treatment, as well as his current research interests.

What drew you to medicine and to vascular surgery in particular?

I had to make an “educated guess” to go into medicine when I was 17-years-old. In Brazil, we have to sign up for the university entrance examination immediately after high school, so there is no transitional period to mature your decision. Clearly, I was not completely sure and debated a bit whether architecture should be my final call. In retrospect, I got it right and could not imagine myself doing anything else. Although my parents and close relatives were not physicians, I admired several of their friends who were surgeons or highly regarded doctors. Some were professors at the medical school. I had a strong sense I wanted to help people and I to use my hands. After I entered medical school it became clear that I had made the correct choice.

All my hard and important decisions were marked by serendipity and a bit of luck. I again struggled when I had to decide to go into surgery, but thought that working with my hands in the operating room environment and being able to change the natural course of diseases with an operation was appealing. I was correct again, and could not imagine myself prescribing pills all day long—surgery became a part of me. Finally, the decision to go into vascular surgery and to come to the United States came together in 1997. I was fascinated by the start of the endovascular revolution and the prospects of a changing specialty with fast incorporation of new technology. The finesse of open vascular reconstructions attracted me more than any other specialty.

Who have been your career mentors and what lessons did you learn from them?

I have been blessed with many “vascular surgery giants” during my training; perhaps I can say I had the best of the open and endovascular worlds. The major influences in my open surgical training were by Drs Peter Gloviczki and Tom Bower. Dr Peter Gloviczki is the consummate master academic surgeon. Not only is he exceptionally skilled and a magician inside and outside the operating room, he is a gentleman, an impressive educator and the most compassionate surgeon I have worked with. He has accumulated the highest accolades that an academic vascular surgeon can aim for, and continues to this date to promote my career with numerous opportunities. He has certainly set the bar very high for us at the Mayo Clinic.Tom Bower is a masterful clinician and surgeon. He had major influence on the way I conduct an open operation. He leaves no stone unturned, is exceptionally skilled, meticulous, and has attention to detail that is second to none. He taught me how to plan and conduct major open reconstructions. Tim Sullivan is responsible for my introduction to endovascular surgery. He is exceptionally skilled and showed that you can be an excellent open and endovascular surgeon. In addition to many teachings, he has been a great mentor academically, a friend and continues to be a major supporter in my career.

But my advanced endovascular skills were really awakened by Roy Greenberg. He really made me think outside of the box. Roy was a friend and a model. He opened my eyes to something I could not imagine before and everything really changed after my experience with Roy at the Cleveland Clinic. He taught me that the aorta is really an organ; prone to diffuse pathology, progression, and that aortic disease should be handled with an eye on how we manage the failure of our treatment, which will come if the patient survives long enough. I consider him the “Yoda” of endovascular aortic repair and credit him for my advanced fenestrated and branched techniques. Most importantly, he made me realise how creative we can be with new techniques, so I continued to evolve a lot after I finished my experience with Roy. His organisation of clinical research and device trials formed the basis for our programme at the Mayo Clinic. Finally, Roy has influenced many of the thought leaders that I admire in our specialty, and of whom I continue to learn through discussions, publications and meetings. To mention a few, Stéphan Haulon, Tilo Kölbel, Matt Eagleton, Tim Resch and Tara Mastracci.

What have been your proudest moments?

My family is my greatest legacy and proudest achievement. My wife Thanila is my coach and “cheerleader” and my children, Gabriel (14) and Victoria (10), are the fuel that keep me wanting to pursue excellence. In my career, the proudest moment or lifechanging event was the chance I was given to train at the Mayo Clinic and to become a consultant. This really changed everything for me. In that moment I entered a new league. I think everything else was a consequence of drive, passion and dedication to perfect the techniques I have learned over the years.

Your research is focused on complex aortic disease – what have been the major advances and what is the greatest need?

Management of complex aortic disease is evolving at a fast pace, making it one of the most exciting areas to practice. Advances have encompassed endovascular devices, ancillary tools, imaging applications, along with extensive experiences from many centres around the world.

The current state is to disseminate these techniques and adopt newer generation devices that aim to facilitate the procedures even further. We are still working on approving devices, training physicians and defining best practices. Over the last decade, several centres published extensive experiences that have helped us better understand different aspects of the procedure, such as learning curve, patient selection, spinal cord injury and results of fenestrations versus branches. Newer ancillary tools have facilitated the technique, making it simpler and faster. Coupled with the technical advances, fixed imaging is totally different than a decade ago. Fusion and immediate assessment with cone beam computed tomography have been instrumental to reduce radiation exposure, facilitate implantation and allow identification of technical problems.

Despite these developments, only a few physicians have access to advanced technology. I am truly hopeful that this will change and that multiple devices by different companies will become available. Finally, we still need refinements in the bridging stents, which are an integral part of these devices and have been neglected in the past.

How have you seen the field develop during the course of your career?

Everything has changed since my foundation years, from how we manage venous, peripheral, carotid or aortic disease. I am privileged to have lived (during my training) through the endovascular revolution and the many changes that occurred in our practice from open to endovascular repair. While I started my career at the Mayo Clinic as an open surgery enthusiast, my practice is currently dedicated to aortic procedures and is 95% endovascular. I believe the specialty of vascular surgery is one of the most exciting in the field of surgery because of its fast-evolving nature. I also believe that vascular surgeons are uniquely positioned to incorporate new technology in their practices, while still being able to perform open or hybrid procedures. As educators in vascular surgery, our concern has shifted to understand how we can develop higher level of open surgical skills among younger surgeons. I cannot emphasise enough the importance of mastering open surgical skills and understanding the concepts of anatomical dissection and open vascular reconstructions. I believe the learning curve for open reconstructions is substantially steeper as compared to endovascular. Open cases are less reproducible and you need to see and do a lot to become a masterful surgeon. With less and less cases, we have increasingly relied on simulation, advanced training paradigms and teams that are dedicated to advance open or endovascular techniques.

What new vascular technology are you watching closely and why?

Our basic tools continue to be stents, wires, balloons and catheters, all under fluoroscopic guidance. And we are still battling bad complications such as stroke, paralysis and dialysis. This has to change. I think we will start seeing newer ways to treat vascular disease that are currently only in our imagination. Can we create stents that are living objects and that will progressively replace or strengthen the aorta, and not be subjected to the fatigue that fabricmetal combination has? Can we go away completely from fluoroscopy and perform these procedures with more precise imaging that does not even involve radiation? All these ideas are still investigational but I believe we will still see a new phase of endovascular therapy that will change our current paradigm. Our job is to stay attentive to change and to be willing to adapt and not become obsolete.

What are your current research interests?

At the Mayo Clinic we have built an advanced clinical research program that is responsible for designing and conducting several prospective studies, many in conjunction with industry. We currently have a team that involves a research manager, two coordinators and two advanced post-doctoral clinical research fellows. We also offer a hands-on three month advanced training on fenestrated and branch endografting. Our team helps conduct over 25 device trials and two physician-sponsored device exemption protocols, which have enrolled nearly 300 patients in a prospective study. Our goal is to provide the highest possible quality of clinical data and level of evidence. We have investigated changes in quality of life and noticed that patients with thoracoabdominal aneurysms have major decline in physical metrics that do not quite return to baseline, even one year after the repair. Our job now is to identify why and how we can change that. We have also analysed a protocol to prevent spinal cord injuries using neuromonitoring, near-infrared spectroscopy and selective temporary aneurysm sac perfusion. Recently, we have presented at the Vascular Annual Meeting (VAM) a comparison of digital subtraction angiography, cone beam computed tomography (CT) and postoperative CT angiography. In that study, cone beam CT detected nearly all technical problems and decreased early reintervention compared to our historical results. We are currently investigating the use of cone beam CT as the only method of immediate surveillance imaging. We hope to present this second phase in the next VAM.

What advice do you hope your mentees/fellows will always follow?

First never take shortcuts in your education just to finish your training a few years earlier. Your formative years are essential to building a foundation for you to continue to grow. To me, the secret of a successful career in surgery is drive, opportunity and determination. Without these three it is difficult or impossible to succeed at a higher level. Your training never ends and you need to adapt. Finally have the patient in the focus of your attention and always aim to do the best for the patient. I assure you will have failures, but at least you will have the comfort of a peaceful mind.

What are your interests outside of medicine?

I am from Porto Alegre, south Brazil, in the state of Rio Grande do Sul, land of gauchos. I am passionate about sailing. As a teenager and young adult, I was a very competitive sailor, representing Brazil in several South American and world championships in the classes of optimist, Snipe and 470s. I now I sail for leisure whenever I can (which is not easy in the Minnesota winter). Next, I am also a surfer; growing up in south Brazil I started surfing at age of eight and can surf reasonably well…but also not easy to surf in Minnesota. I am always doing some sort of fitness exercise. I went through P90X, Insanity, T25 and cross training programmes. In the last several years, I have been an avid runner, completing half and full marathons. I would say that is what I currently do more often, but when I see the water and a boat, I give up on the running right away!

My main interest is my family, Thanila and our two kids—Gabriel and Victoria. We are always together whenever we have any free time doing family activities. I love music and cinema and have an eclectic taste for the classic and the 1990s in general.

Fact File

Current appointment

Chair of the Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, USA

Professional career (all present)

• Consultant, Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic
• Professor of surgery, Mayo Clinic College of Medicine and Science
• Programme director, Vascular Surgery Integrated Residency, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science
• Programme director, Vascular Surgery Fellowship Program, Mayo Clinic of Medicine and Science
• Programme director, Vascular Surgery Advanced Aortic Fellowship, Mayo Clinic College of Medicine and Science
• Director, Aortic Center, Department of Surgery, Division of Vascular and Endovascular Surgery

Professional highlights

• Chair, Reporting Standards Fenestrated and Branched Endografts, Society for Vascular Surgery
• Associate editor, Annals of Vascular Surgery
• National principal investigator, Cook Thoracoabdominal Branch Stent Graft Trial and ZFEN Plus Stent Graft Trial

Editorial board:

• Journal of Vascular Surgery
• Journal of Endovascular Therapy
• Vascular
• Surgery
• Perspectives in Vascular Surgery and Endovascular Therapy
• Indian Journal of Vascular and Endovascular Surgery
• Brazilian Journal of Vascular Surgery
• Spanish Journal of Surgery Research and Annals of Vascular Surgery