Being the first to use a hybrid endovascular operating room in Italy is one of Piergiorgio Cao’s proudest moments. At the beginning of his career, he worked as a fellow with the legendary cardiovascular surgeon Denton A Cooley in Houston, USA, and is now chief of Vascular Surgery at San Camillo Hospital, Rome, Italy. Cao spoke to Vascular News about his aspirations to examine the healthcare organisation in his home country and his passion for mentoring his children (both medical students), skiing and country living.
When did you decide you wanted a career in medicine? Why vascular surgery?
It was a last minute choice when I was 18, just a few weeks before the deadline for the application at university. Being uncertain between law (my father was a lawyer) and medicine, I finally decided to take care of patients as a philanthropic purpose fascinated me (something very common at this age and during the late sixties). During my years at medical school, quite soon in, I felt that surgery would be my field. I started my student rotation and subsequently my internship at the Department of Surgery, directed by Paride Stefanini, University “La Sapienza” in Rome. I had chances to scrub in on some vascular cases with him and then with Paolo Fiorani (the Division of Vascular Surgery was just starting). I felt that vascular surgery was particularly challenging because of the required technical skills and the wide range of diseases to treat.
Who has inspired you in your career and what advice of theirs do you remember today?
I basically had two mentors in my professional life: the first was Luigi Moggi, from the University of Perugia. He was my first boss (surgical departments in Italy are very hierarchical), and one of the first general surgeons in Italy with great experience in vascular cases. His attitude to teaching was to encourage the young trainees to get a wide spectrum of training experience abroad as well as technical surgical knowledge and learning to empathise in our relationships with the patients; it was the most important lesson that I received from him. My second mentor was Denton A Cooley. I spent almost two years as a fellow in his department in Houston, USA, when he was probably at the highest point of his career as a giant in cardiovascular surgery. The most important advice I got from him was that cardiovascular surgery should be simple and easy to control even in the most difficult cases.
What have been your proudest moments?
I can recall several proud moments in my professional life, but probably the following three were the proudest: the first was when I received the letter from the Baylor School of Medicine in Houston with the appointment as a clinical fellow in cardiovascular surgery at the Texas Heart Institute in 1978. The second was in 1996 when I performed my first abdominal aortic endografting. The third was in 2006 when I started to use the hybrid endovascular operating room (OR) in Perugia, one of the first in Europe and the first in Italy. It was my plan since early 2000 to use the hybrid endovascular OR and it took me at least three years to convince the hospital administration and to design, with the engineers, the new facility consisting of two dedicated vascular theatres (one hybrid) with a recovery room fully equipped with the latest technology.
How has vascular surgery evolved since you began your career?
The turning point in vascular surgery was in 1997, when EVAR was diffused into many vascular centres because of the introduction of the new, easy-to-use, commercially available endograft. Since then, most vascular diseases can be approached, at least as a first step, with endovascular means. This greatly decreases the invasiveness of procedures, completely changing the clinical practice. Since 1997 it became clear that the use of catheters, wires, balloons and endografts were not prerogatives of a radiologist or cardiologist anymore, but with adequate training they should be prevalently used by the vascular surgeon – the only vascular specialist that can offer dual options of treatment according to different clinical findings about the patient. The other side of the coin is that the adoption of endovascular procedures in most “easy” cases decreases the case load of open surgery available to train our residents, which increases the risk of a decline in the quality of training.
What have been your most memorable clinical cases?
There have been several memorable cases. In 1999, a 17-year-old boy had a motorcycle accident which caused thoracic aorta rupture. I treated the patient with an abdominal tubular endograft introduced via the abdominal aorta (at that time the device length did not allow use of the transfemoral route to reach the distal aortic arch). That patient is doing very well 13 years after the procedure. Also, another important case was the one of a patient who had type II thoracoabdominal aneurysm with a branched endograft. The surgery was performed in San Camillo Hospital in Rome after the case had been refused by many other hospitals in Italy and the patient was discharged on the sixth postoperative day. Another memorable case was my first EVAR in 1996.
How do you see the endovascular field developing in the future?
To further develop the endovascular field we need technological improvements in terms of miniaturisation of the devices and material durability. However, it is also crucial to guarantee adequate training in open surgery and to develop endovascular skills and knowledge of materials in trainees. This opens up the critical issue of centralisation of major vascular operations. In several countries there are many centres that are performing a limited number of procedures at the risk of decreasing the quality of care and increasing the cost. I think that the vascular community and societies should address and solve the problems with standards of care.
You worked as visiting surgeon and visiting professor in the USA and Sweden on several occasions over four decades. What have these experiences added to your career?
My multiple experiences abroad have given me different incentives throughout my professional life. In the early years, it was to learn different techniques, and then to learn about different department organisations. Currently, it is to compare various modalities of teaching with teaching at my own country. These experiences are a continuous stimulus for me to maintain an adequate standard.
Can you please describe your first case of aortic endografting?
In November 1996, I had my first EVAR case after only one week training with mechanical models and multiple studies on the topic in a lab in The Netherlands. This case was performed in an OR with the first generation of portable digital C-arm, the best technology available at the time (but completely different from today!). I, one interventional radiologist, and one vascular surgeon as assistant were the operating team. One clinical specialist, plus two engineers from the company were also present in a very crowded OR. The graft was made by Endovascular Technology (EVT). The single piece was a bifurcated endograft, unstented, with hooks proximally and distally, and contained in a 27F device, if I remember correctly. There was very poor visibility of the markers under the X-rays, and it was very difficult to avoid twisting the limbs. Nevertheless, after four hours the procedure was completely successful. The patient survived seven years and died of a heart attack.
You were the principal investigator of the CAESAR trial. What had this study added to what we know in aortic aneurysms treatment?
I have to admit that to conduct a multicentre randomised trial without government or other forms of public funding is extremely difficult. However, we reached important results. Basically, the CAESAR study confirmed what was previously known from the UK Small Aneurysm and ADAM trials. We found out that the majority of aneurysms between 5cm and 5.4cm require treatment within two years because of enlargement or other complications and frequently lose the EVAR morphological feasibility. This diameter range represents a grey area in which, according to morphological and clinical findings, EVAR may be indicated below the threshold of 5.5cm.
What are your current areas of research?
Today, my research is focused on early and late outcomes of total endovascular repair of thoracoabdominal aneurysms. We have a common database of branched endografts of Rome and Perugia. We are currently analysing the fate of visceral arteries in these patients and evaluating different projects of branched endografts. I am also reviewing all the results of TEVAR in type B dissections performed in Rome, and, at the same time reviewing the literature on this topic. A paper is under revision by the Journal of American College of Cardiology.
What is the most interesting paper you have come across recently?
I think the paper recently published in Archives of Internal Medicine on “statins and cardiovascular risk meta-analysis” which includes more than 40,000 patients and shows a reduced risk for all cardiovascular events in men and women, and may represent the most relevant contribution this year in clarifying the best medical treatment for vascular patients.
What skills does the endovascular surgeon of the 21st century need to develop?
In my opinion the endovascular surgeon should not be considered an independent professional entity but included in the specialisation of vascular surgery as a whole. The vascular surgeon should be equally trained in open and endovascular operations. As far as endovascular skills are concerned, manipulation of guidewires is a crucial aspect of any procedure. Confidence in imaging interpretation and software reconstruction should not be delegated to other specialists. Procedure planning has to always be directly performed by the vascular surgeon. Robotic systems for endovascular procedures are still in their very early phases but may have a role in the future.
Outside of medicine, what are your interests?
Outside of vascular surgery (but not medicine) my interests are to study the health organisation in Italy. I also want to impart to my son and daughter (both are medical students) what I have learned regarding clinical and research methodology. I also enjoy skiing in winter, being in the wilderness and at the sea during summer and a life in the countryside.
1972 Graduated with honours, University of Rome Medical School
1977 Residency in General Surgery, University of Rome “La Sapienza” Medical School
1982 Residency in Vascular Surgery, University of Rome “La Sapienza” Medical School
1978 VISA Qualifying Examination, National Board of Medical Examiners (USA)
1978 ECFMG (Educational Commission Foreign Medical Graduates, USA) exam
1978– 1979 Clinical fellow in Cardiovascular Thoracic Surgery at the Texas Heart Institute, Houston, USA
1994– 2009 Chief of the Division of Vascular and Endovascular Surgery, Ospedale S Maria della Misericordia, Perugia, Italy
2005–2006 Associate professor of Vascular Surgery, Università degli Studi di Perugia, Perugia, Italy
2006–present Professor of Vascular Surgery, Università degli Studi di Perugia
2009–present Chief, Division of Vascular Surgery, Azienda Ospedaliera San Camillo – Forlanini, Roma, Italy
1976–1978 Division of Vascular Surgery, Pennsylvania Hospital, Philadelphia, USA
March 1978 Division of Cardiovascular Surgery Texas Heart Institute , Houston, USA
December 1986 Division of Vascular Surgery, Northwestern University Medical School, Chicago, USA
March 1994 Division of Cardiovascular Surgery, The Methodist Hospital, Baylor School of Medicine, Houston, USA
April 1994 Division of Vascular Surgery, Massachusetts General Hospital Harvard Medical School, Boston, USA
February 1994 Division of Vascular Surgery, Pennsylvania Hospital, Philadelphia, USA
March 2003 Mälmo Endovascular Center, Mälmo University, Sweden
June 2006 Department of Surgery, Stony Brooke University of New York, New York, USA
September 2007 Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, USA
May 2008 Department of Radiology, Karolinska Institute, Stockholm, Sweden
March 2011 Department of Vascular and Endovascular Surgery, Stanford University, Palo Alto, USA
June 2011 Division of Vascular and Endovascular Surgery and Gonda Vascular Center, Mayo Clinic, Rochester, USA