Maarit Venermo was driven to a life in medicine by her competitive nature and arrived at medical school with little idea of what speciality she would end up in. As is so often the case, it was an influential mentor that guided her towards vascular medicine, and she never looked back. Venermo soon found herself at the forefront of Finnish vascular surgery as it became its own subspeciality. She spoke to Vascular News about her early career, how the rise of endovascular technology has coincided with the maturation of the field of vascular medicine, and what pearls of wisdom she would pass on to the next generation.
Why did you decide you wanted a career in medicine, and why in particular did you choose to enter the vascular field?
To be honest the reason I wanted to apply to medical school was the fact that it is one of the most difficult places to get into. When I started in medical school, I had no idea of the speciality I would choose, but it became very clear to me in 1991 after the fifth year in medical school when I worked during a summer holiday as a fellow in the department of surgery. The choice of subspecialty happened in Satakunta Central Hospital where I worked as a fellow for three years after graduating from medical school. It was a “hero surgeon” Jorma Hannukainen, an extremely skilful vascular surgeon, who led me to the field of vascular surgery. He is not only a skilful surgeon but also has a great intellect.
Who have been your most important career mentors and what wisdom did they impart?
At the beginning of my career, it was a privilege to work in Satakunta Central Hospital, whereas a young fellow I had the opportunity to learn and perform a wide range of surgeries. Jorma Hannukainen taught me the basics of vascular surgical techniques. He taught that everything should be questioned, and indeed he did. He also had a lot of research ideas and thanks to him I did my first randomised controlled trial at that time. I left Satakunta to become a surgeon and vascular surgeon in Tampere University Hospital. There my mentor was Juha Salenius, who introduced me to the field of vascular registries. The most important wisdom I gained from him is that if you believe in your ideas, everything is possible. It was a windy period in Finnish vascular surgery as we became an independent subspecialty. A few years later, after spending a postdoctoral year at Stanford University, I was very happy to become the first adjunct professor of our new subspecialty in Finland. Mauri Lepäntalo, who has had the greatest spirit of all my mentors, and still is my mentor, has shown how important it is to inspire the whole team to get results. Mauri really had a great passion to treat and study critical limb ischaemia, especially the diabetic foot. Mauri also taught me that “if you do it, document it. If you document it, do it. If it is not documented, it never happened”.
What has been the biggest development(s) in vascular medicine during the course of your career?
Of course the biggest one is the endovascular tsunami, which has especially changed the treatment of abdominal aortic aneurysms and aortoiliac occlusive disease. At the beginning of the 1990s, one of the most common open operations was aortibi-iliac or -bifemoral bypass due to abdominal aortic aneurysm or peripheral artery disease. Nowadays, the great majority of the patients undergo endovascular treatment. The first EVAR in Finland was done in 1996, at the same time that I started my specialisation in Tampere University Hospital. Although the technique has had its problems, especially at the beginning of the 2000s, the developments of thoraco-abdominal techniques and treatment of ruptures really benefits the patients. Secondly, best medical treatment has improved significantly as the statins and antithrombotic agents have really improved patient outcomes. A third area to mention is vascular imaging, as a revolution has happened since we staretd using printed angiogram films in 1990s.
What is the most interesting paper or presentation that you have seen recently (aside from your own research)?
New results from randomised controlled trials are always exciting, thus the recent long-term results of the EVAR 1 trial, as well as the three-year results from the IMPROVE trial, have been the most interesting ones.
What are your current research interests?
We have several projects going on with 12 PhD students in the field of critical limb ischaemia, drug-eluting balloons, hybrid procedures, and aorto-iliac aneurysms, as well as the impact of best medical treatment in patients with lowered toe pressures and ankle-brachial index. I am most excited about the indocyanine green fluorescence imaging in patients with critical limb ischaemia and the impact of both surgical and endovascular revascularisation on perfusion in the different regions of the foot. We also have really interesting results in our randomised controlled trial comparing drug-eluting balloons and plain balloon angioplasty in lower limb bypass stenosis and dialysis access. I am also very excited on the power of registers in research as I have been in Vascunet co-operation since 2005 and been the chairman of the group for the last three years. We have several projects going on with VQI and I myself have been engaged with the analysis of the carotid surgery and variation between the countries and continents. In the future I hope we can proceed in a project with Imperial College, Roger Greenhalgh and his group, about the effectiveness and cost-effectiveness of endovascular aneurysm repair.
At the recent CX meeting in London, you took part in a debate discussing the angiosome concept. Can you explain the concept and why there is disagreement on its utility?
The concept is simple and logical in my mind. According the angiosome concept, in crural peripheral arterial occlusive disease (PAOD), you should revascularise the artery feeding the angiosome where the tissue lesion exist in order to achieve the best possible wound healing and leg salvage. When we started to investigate the angiosome concept in critical limb ischaemia, I was very critical myself about it. My theory was that tissue lesion does not exist in one angiosome, and I had doubts about the possibility to choose angiosome targeted revascularisation in widespread PAOD. Also, many of those who criticise say that there are always collaterals which take care of the perfusion across the angiosomes. According to our studies it seems to be important in endovascular revascularisation to choose the vessel according to angiosome concept, however, when you do a distal bypass, it seems that perfusion also increases in adjacent angiosomes and it seems not as important as in the endovascular repair to choose the vessel according to angiosome concept. We have also seen that indeed, collaterals do have an influence, but the perfusion after endovascular revascularisation does not seem to increase as much in the regions that are revascularised through collateral compared to direct revascularisation.
At your centre, you have worked to establish simulation training for ruptured abdominal aortic aneurysm. Could you explain how this training programme was established and what benefits you have seen so far?
When we started to treat ruptured abdominal aortic aneurysm patients with EVAR in larger volumes in 2010, we had a clear problem: the preparation of the patient took too long and sometimes it took as long as three hours to get everything ready to start. The ruptured EVAR procedure itself does not differ much to the elective procedure, the management of occlusion balloon is the only difference. But as we are only a limited number of vascular surgeons performing both elective and emergency ruptured EVAR, the procedure itself has not been a problem. The idea of starting simulations came from my dear colleague Pekka Aho, who is one of the coaches in simulation sessions. In 2014 we created a new ruptured aneurysm protocol and at the same time started to plan how to run simulation sessions with a patient simulator. The key people besides vascular surgeons have been anaesthesiologists Leena Vikatmaa and Leila Niemi-Murola and nurses Ville Päivinen and Mia Kantomaa, who have education in arranging simulation training and experience on the resuscitation simulations using the same patient simulator. A great advantage was that we got permission to arrange the sessions in the real environment, in our hybrid theatre. The sessions themselves have developed a lot during the almost two-year period we have been arranging them, as every time we try to learn something from the session to be able to arrange a better session next time.
Could you tell us about one of your most memorable cases?
This is difficult as there are so many cases. A couple of months ago I was operating with on a patient with critical limb ischaemia and large tissue loss in the foot. There was only a branch of ADP in the foot, where we built a distal bypass with spliced veins and the distal vessel was an extremely tiny artery. The flow in the end was 10ml/minute and we were sure that the bypass would be occluded within a week. However, it is still open and the foot of the patient is okay. It reminded me once again that pedal bypass can be magic! Another case we treated lately, which did not go as well, was a 84-year-old male with a ruptured thoraco-abdominal aneurysm, and we treated him with branched EVAR without any problems. The patient recovered well out to 12 hours, but thereafter he became paraplegic and paresthetic distal to diaphragm. This reminded me that although we are able to do technically successful cases, there are so many other variables, especially in ruptured cases where you are not able to avoid hypotension in the beginning and in old patients you should really be careful to think about the all possible consequences and quality of life of the patient.
What are some of the proudest moments in your career?
There are two types of “proud moments”; when I have achieved the next level of a learning curve in surgical skills or when our team has great achievements in research. An example of the first type is when I was, for the first time, alone all weekend on call in vascular surgery in Tampere. I was still a fellow in vascular surgery and I had earlier operated on one ruptured abdominal aortic aneurysm patient with senior vascular surgeon Rainer Zeitlin. During the weekend there were two rupture patients who I operated on and they both survived. It was the same kind of feeling when we started the ruptured EVARs in local anaesthesia and complex aneurysm cases with fenestrated and branched EVARs with good results. Of course it was a great moment to become the only full professor of vascular surgery in Finland in Helsinki in 2014. Now that we have a really active and great young group, I am very proud to see them presenting our research results in international podium presentations, not to mention when they finalise their PhDs. Within the next three weeks we will have two dissertations as Kristyna Spillerova will defend her thesis “The role of angiosome concept in the treatment of below-the-knee critical limb ischaemia”, while Matti Laine is defending his thesis “Ruptured abdominal aortic and iliac artery aneurysms”.
What three questions in vascular medicine still need to be answered?
The three questions I would like to see answered during my life are: 1) Why does an artery become aneurysmatic and how we could prevent this development? 2) How can we prevent atherosclerosis and how can we prevent restenosis and re-occlusion of an artery after endovascular treatment? 3) What is the objective and absolute truth about endovascular revascularisation in patients with ischaemic tissue lesion and widespread arterial occlusive disease?
What advice would you give to young vascular surgeons starting out in their careers?
I would like them to remember that intervention is not always the best option for a patient and that they can probably do more good in many cases by treating the patient with best possible conservative treatment (for example, a great proportion of claudication patients). At the same time, I would like them to intervene with low thresholds when there are indications to do so! I would like to encourage them in their career to believe in themselves. Unfortunately, nothing comes for free, which means that you have to practice a lot and read a lot. Furthermore, it is always beneficial to visit other vascular units and see how things are done elsewhere because no matter how good you are, you always learn something. The last thing but by no means the least: as vascular surgeons, you should never start avoiding open surgery and do only endovascular tricks, because soon you will forget how to operate, then you start to avoid it even more!
2012–present Head of Department, Vascular Surgery, HUCH Abdominal Centre, Helsinki University Hospital, Helsinki, Finland
2014–present Professor of Vascular Surgery, University of Helsinki, Helsinki, Finland
Education and training (selected)
1992 Licensed Physician, Turku, Finland
1993 Registration, Turku, Finland
1999 Specialist of General Surgery, Tampere, Finland
2001 Specialist of Vascular Surgery, Tampere, Finland
2003 PhD (accepted with honourable mention)
2005 Adjunct professor in Vascular Surgery, Tampere, Finland (this was the first in Finland for the subspecialty of vascular surgery)
2005 Master of Quality, Helsinki University of Technology, Helsinki, Finland
2012 Adjunct Professor in Vascular Surgery, Helsinki University, Helsinki, Finland
2003–2004 Stanford University, Laboratory of Vascular Biology, Stanford, USA
2006–2011 Consultant Vascular Surgeon, Helsinki University Hospital, Helsinki, Finland
2002–2006 Consultant Vascular Surgeon, Tampere University Hospital, Tampere, Finland
1999–2001 Fellow, Department of Vascular Surgery, Tampere University Hospital, Tampere, Finland
1997–1999 Resident, Department of Surgery, Tampere University Hospital, Tampere, Finland
1994–1997 Resident, Department of Surgery, Satakunta Central Hospital, Pori, Finland