Vascular News talks to Dr Michel Makaroun, Professor of Surgery, University of Pittsburgh School of Medicine, Chief, Division of Vascular Surgery, about why he entered into medicine, his greatest influences and the need for data before widespread acceptance of the latest technologies.
When did you first decide you wanted a career in medicine?
I fell into medicine by mistake; after high school, I actually wanted to attend an engineering school in Paris but at 16, I was not allowed to travel outside Lebanon. As a result I decided to enroll in a two-year course at the American University of Beirut just to reach 18 so I could travel. I ended up enrolling in pre-med as it was the only two-year curriculum at AUB. I have been in medicine ever since.
What made you enter vascular surgery in particular?
When I finished my general surgical residency at Pittsburgh I was not quite sure where I was heading in terms of specialty or country for that matter. I had always enjoyed the technical aspects of vascular surgery and I think it appealed to the engineering side of me. My chairman asked if I would start a vascular service at the adjacent Veterans Administration hospital, and I thought that would be a great idea. So I entered into vascular surgery.
Vascular surgery is unique in that you treat problems all over the body as well as various disease processes, from aneurysms to occlusive disease. Also at the time, there really was no medical counterpart to the vascular surgeon, so we took care of everything involving vascular problems and we were always looked upon as the experts in vascular disease. I remember we used to get consultations for vasospasm, connective tissue disorders, hypercoagulable states and arteritides, not really the traditional domain of a surgeon. That is what we continue to do today – treat the patient from a medical perspective, a surgical perspective and gradually we have grown into the interventional side, which has increased the variety and appeal of vascular surgery. We also provide non invasive diagnosis as well as long term follow-up. Great variety!
How has the endovascular era changed this?
Well, it is getting crowded. The radiologists have been involved with vascular intervention for a long time, and were pushing for the adoption of new interventional techniques. Vascular medicine became a specialty. Cardiologists recently developed an interest in peripheral disease adopting interventional techniques and some are even diverting their interests from the coronary to the periphery and those do a tremendous job in taking care of patients. Unfortunately, some cardiologists are trying to take care of peripheral disease part-time and this does not work as well. We are witnessing also the development of interventional neurosurgeons, nephrologists and neurologists, and this has lead to a blurring of the roles of who is taking care of what and are they really doing the best by their patients? Fortunately the vascular surgeons continue to have a prominent role in the management and development of newer endovascular techniques. I am glad we did not rest on our laurels. Our specialty if anything is booming.
Who were you greatest influences?
I had three unbelievable mentors at Pittsburgh when I was a resident and I think all of them, as it turned out, played a significant role in my career. The first was Henry Bahnson, who was Chairman of Surgery in the 1960’s to the late 1980’s. He came from Hopkins to start the program at Pittsburgh and was the President of almost every surgical society. He performed many firsts in vascular aortic procedures both here and in Europe. He was a master technician and one of the most straightforward, honest and direct people I have ever met. He was actually the one who got me involved in surgery and vascular surgery, and promoted my career early on. From him I learned to be direct and honest. He was also a man of few words; unfortunately I did not pick that one up!
The second one was Thomas Starzl, who at the time was struggling through the promotion of liver transplant. He is probably one of the most tenacious people I have ever met. When he went after a goal he would never stop at anything until he finally got it right. From him I learned not to let bumps in the road detract from the ultimate goal.
The third one is Mark Ravitch, who is probably one of the smartest people I have ever met. He introduced and promoted stapling devices in the US to simplify and automate procedures. He taught me to be critical of data and accepted norms, and that I should always challenge the prevailing attitudes. I would say that those three have influenced me the most.
On a professional level what have been your proudest moments?
The proudest and most exciting moments have been my involvement with endovascular aneurysm repair in the mid-1990’s and the most satisfying was when it was approved by the FDA. I am also proud to have been involved in teaching this new technique and promoting it, as it is in my opinion a much better way of treating aneurysm disease.
You began your medical education in the Lebanon and then moved to the US. What were the most significant differences between the two countries?
There are so many it would be hard to mention them all. When I left, Lebanon was very chaotic, there was a war going on, there were no rules or regulations and it was not very conducive to stability, innovation or career development. However, it did provide me with an incredible opportunity as we were thrown into performing surgical procedures even as third year medical students. As interns, we were left alone to perform laparotomies as there were no surgeons available. The AUB prepared me well for the medical advances practiced in the US but what first struck me were the multitude of checks and balances, quality assurance, accountability structures and organisations involved; also unfortunately the significant bureaucracy, which sadly limits certain things in the US. It was also kind of amazing to note how accessible tests and imaging were and how much reliance there was on them. I had never also heard of liability and medical malpractice lawyers before I came to the US. Quite interesting!
A lot of your research has concentrated on carotids and aneurysm (thoracic and abdominal), what drew you towards these areas in particular?
I guess over the years my interests have changed but I started focusing on aneurysm disease in the early 90’s. What drew me toward aneurismal disease was the changing technology towards endovascular intervention. I was introduced to it long before I was able to get involved. I ran into some of those developing the EVT endograft at Endovascular Technologies company in the early 1990’s when they were still trying to establish the protocol and the final design, and I was intrigued and fascinated with the ability to treat aneurismal disease with such an elegant, minimally-invasive procedure.
I was also involved in one of the early AAA trials, the Aneurysm Detection and Management (ADAM) trial at the VA hospital. At the time we did not see or treat as many aneurysms and those we did were mostly when they ruptured, but this trial enhanced the awareness about AAA and our volume skyrocketed. I was quite interested to see what we could do to treat this disease, and at this time there was a lot happening in the field, such as endovascular treatments and the
UK Small Aneurysm Trial.
Carotid disease is also fascinating. My interest began as I was involved very early on in the late 80’s in both the asymptomatic and symptomatic trials of carotid endarterectomy (VA cooperative trials as well as the NASCET). But a very interesting technique that we were using in Pittsburgh in the late 1980’s, stable Xenon cerebral flow maps of various parts of the brain, helped me become very interested in the engineering aspects of cerebral blow flow and its regulation, the causation of stroke and the effect of carotid stenosis and occlusion. Then we formed a stroke center with our neurology and neurosurgery colleagues which continued to stimulate my interest in carotid disease and additional interesting developments including stenting have maintained my interests.
What was your reaction to the CMS decision not to expand coverage to carotid stenting?
I think it was the right decision and I am pleased that it has given us a little more time to finish important trials such as CREST. The political forces in the US are not yet aligned to completely expand the coverage. It is an expensive technology when you start employing it for everybody and we do not yet completely understand its place in our armamentarium. I am not entirely sure that we have proven yet that the treatment of asymptomatic disease per se in the modern day era is something that needs to be done. We really do not know anymore what is the medical natural history of the disease after the introduction of statins, ACE and platelet inhibitors, and other medical innovations. We need more data before we start accepting technology blindly and I am afraid that once it is approved we cannot enrol patients in trials to find out more.
The ongoing trials in the US, Europe and internationally will tell us more about the disease process and the different ways to treat it in the next couple of years. There is plenty of evidence now that statins can stabilize plaques both during and after intervention. The benefit of intervention in asymptomatic disease is so thin that you can easily tilt the balance on way or the other with some additional medical advances. I would hate to think that we are submitting thousands of people to interventions they do not need.
There were very positive results at the recent SVS conference from thoracic aneurysms trials (STARZ-TX2, VALOR and GORE), do you believe that TEVAR is now ready to replace in open repair in suitable patients?
In my mind all the interventions must be measured against the prevailing surgical options available. For carotid endarterectomy the surgical option is so good that it is going to be somewhat hard to actually beat it very easily. For thoracic disease the surgical option is so morbid it is just about impossible to think how anyone would choose the surgical option over thoracic endovascular repair for most thoracic pathologies. I think it should be the ’gold standard’ and I cannot see how anyone can look at the data and conclude that we need to delay the decision-making process to get more information. For all suitable patients the endovascular option should be the primary option. For unsuitable patients, a hybrid procedure maybe the preferred solution compared to the pure surgical option. In a few years, I believe that just about any thoracic aortic pathology will be treated with an endovascular technique.
Although we only have access to one device, the use of TEVAR in the US has been readily adopted and some 50% all thoracic pathologies are treated by endovascular means. The morbidity of open repair has resulted in widespread acceptance of TEVAR compared to abdominal or carotid endovascular intervention, where there are some critics of the long-term results.
Outside of medicine what other interests do you have?
I love to travel, I enjoy visiting different places and I am lucky that my career has allowed me to go to many international meetings. I think Europe is probably my favorite place as the European way of life somewhat reminds me of Lebanon. I also enjoy listening to music and reading, however I don’t really have as much time as I like to enjoy this. I am looking forward to the day that I don’t have to work as hard. My wife tells me it is the day I die!
Michel S Makaroun, MD
Born: Lebanon, 1 August 1954
Citizen of the USA
1971–1973 American University of Beirut
1974 BS, Biochemistry, Medical School, Beirut
1973–1978 American University of Beirut
1978 MD, Medicine, Medical School, Beirut
1977–1978 Surgery internship, American University of Beirut
1978–1980 Surgery residency, American University of Beirut
1980–1983 Surgery residency, University Health Cente r of Pittsburgh, USA
1983–1984 Surgery research fellowship, University of Pittsburgh
1984–1985 Surgery administrative chief, University Health Center of Pittsburgh
1985–1986 Vascular Surgery Fellow, University Health Center of Pittsburgh
· University of Pittsburgh School of Medicine, Department of Surgery
1984–1986: Clinical Instructor
1986–1992: Assistant Professor of Surgery
1992–now: Associate Professor of Surgery
1999–now: Chief, Division of Vascular Surgery
2000–now: Professor of Surgery
· University of Pittsburgh Medical Center: Presbyterian University Hospital
· Montefiore University Hospital
1984–now: Active Staff
1993–now: Medical Director, Peripheral Vascular Laboratory
1995–now: Director, Endovascular Surgery Program
1998–now: Program Director, Vascular Surgery Residency
Society Membership (edited)
1987–now: Allegheny Vascular Society – President, 1999-2001
1987–now: Eastern Vascular Society – Secretary 2006-present
1988–now: Fellow, American College of Surgeons
1989–now: Society for Clinical Vascular Surgery – Secretary 2006-Present
1994–now: International Society of Endovascular Specialists
1997–now: Society for Vascular Surgery – Distinguished Fellow 2003-Present
1998–now: American Lebanese Medical Association
1999–now: Stroke Council, American Heart Association
1999–now: Association of Program directors in Vascular Surgery
2001–now: Journal of Endovascular Therapy, Editorial Board
2002–now: Vascular And Endovascular Surgery, Editorial Board
2004–now: Vascular, Editorial Board
2004–now: Journal Of Vascular Surgery, Editorial Board.