Vascular News talks to Dr Kenneth Ouriel, Head of Surgery at the Cleveland Clinic, Ohio about his career in vascular surgery and why he loves a hands-on role in running clinical trials.
Discovering vascular surgery
Until he was 13 and beginning high school, Dr Kenneth Ouriel had his heart set on becoming an engineer or an architect.
“But my parents, specifically my mother, told me the market for engineering and architecture in the US at that time was terrible, and that I wouldn’t be able to support myself or my family,” he told Vascular News.
“What she did suggest, however, was I become a doctor’.”
With this thought in mind the teenage Ouriel joined a group called Explorer Scouts, whose activities included expeditions to the hospital.
“Renal dialysis was one thing we looked at, I remember, which at that time was a machine that was about as big as a commercial washing machine,” Ouriel recalled.
“I decided medicine was what I wanted to do. My secondary school subjects were geared towards that – I focused on maths and science rather than English and art.”
Ouriel went to high school for only three instead of four years, beginning college at 16 and medical school at 20. His original passion for architecture and engineering – combined with his new medical knowledge – quickly attracted Ouriel to surgery.
“If you could pick one part of medicine like engineering or architecture, it is surgery,” he explained.
“That’s also why, early on in my career I became interested in medical devices, which fits in very nicely with surgery.”
His natural love of design and structure saw Ouriel enter medical school originally wanting to be an orthopedic surgeon.
“But when I went through my first couple of years at the University of Chicago I realized that with orthopedics I’d be very focused on a small part of medicine – I could pretty much forget about the heart and brain,” Ouriel said.
“I didn’t want to lose everything I’d learned and was interested in, including things such as metabolism and circulation. So I didn’t go into orthopedics, but I was still interested in surgery. I just didn’t want to focus on just one area, like the colorectal surgeon is just focused on colon.
“The reason I picked vascular surgery was because it involved the neck, the leg, the chest, the abdomen – everywhere.”
Ouriel was also influenced by an early career mentor at the University of Chicago, a vascular surgeon named Chris Zerins who is now the chief at Stanford.
“I did some research with him, went to the operating room with him. I knew I wanted to do vascular surgery from the time I was a third year medical student.”
Another factor that initially attracted Ouriel to vascular surgery was the extra element of patient care, allowing him to use his medical training.
“At that time there was cardiologists for cardiac surgery, but there was no vascular medicine practitioner, at least in the US. So I could practice both medicine and surgery by doing that specialty,” he said.
“I could take care of my patients medically and surgically. Now things have changed a bit, there are medical practitioners who take care of vascular surgical patients. Vascular surgeons take care of their own patients’ medical problems to a much smaller degree.
“But initially you became the medical practitioner for vascular problems. Not every patient needs an operation – for example, Raynaud’s Disease, where you get color changes in the digits. That’s a medical, not surgical, problem – but vascular surgeons are still the ones who primarily take care of it in the US.”
After completing medical school Ouriel went to the University of Rochester for a five-year residency and a one-year vascular surgical fellowship. After six years of training he joined the staff at Rochester, where he stayed from 1987 to1998. In 1998 he joined the Cleveland Clinic to head vascular surgery, a position he held until 2003 when he took on his current role as Cleveland’s Chief of Surgery. The division of surgery comprises of 14 specialties, including plastic surgery, vascular surgery, general orthopedics and others.
“We’ve just named our next chief of vascular surgery at the clinic, which is Dr Michael Silva.”Ouriel said.
Leading clinical trials
Ouriel is passionate about getting directly involved in running the latest clinical trials.
“At the Cleveland Clinic we don’t like to just be a trial site – we like to head the clinical trials, which we’re currently doing for quite a few,” he said.
“We’ve been very big in the aortic endograft trials – not so much from heading the clinical part but in running the so called core-lab, which is the imaging laboratory which does all the measurements on the aneurysms after an endograft has been placed.
“We were the core lab for the Guidant device, and for Cook, Gore, Cordis and now Vascutek. Now we’re also heading the Medtronic small aneurysm trial (PIVOTAL trial), which is taking up a large part of my time.”
Ouriel was also the only surgeon on the four-member executive committee of the SAPPHIRE trial, headed by Cleveland colleague and close friend Jay Yadav. His enjoyment comes from “being in the heart of things – designing the research and executing the clinical trial”.
“The one thing I don’t like and am least good at is probably the most important part of any clinical trial – making sure the patients are recruited into it,” he said.
“That’s the sales side and I’m not very good at the follow-up calls and emails – I’m not a sales person!”
The majority of trials Ouriel has been involved in have been industry, rather than government, funded. The thrombolytic trial from the late 1990s, one of the biggest clinical trials the clinic has been involved in, was funded by Abbotts Labs. SAPPHIRE was funded by Cordis and the PIVTOAL trial by Medtronic.
“For me industry funding is a better route because it is quicker and the process less onerous,” Ouriel said.
“Whereas with Government funding: you have an idea, design the trial, have your protocol done and submit it for funding – but it might be four years before you can do the trial and by then it’s too late, things have changed. That said, I am the PI of an NIH ROI trial aimed at plaque regression in peripheral arteries.”
CAS vs Carotid Endarectomy
Ouriel is a firm believer for carotid intervention in asymptomatic patients – something he took to the stage about at the recent 27th Charing Cross International Symposium Global Endovascular Forum.
“We have all of this data to suggest we should be treating asymptomatic patients with carotid endarectomy if the stenosis is severe. We have data from SAPPHIRE that show stenting is probably better than endarectomy – not just equal but better – in asymptomatic patients, high risk cases,” he said.
“So all we have to do is make this small leap and say ‘well if endarectomy is better than nothing, if stenting is as least as good as endarectomy, then stenting should be better than doing nothing’. But we haven’t made that leap because number one, many of us are conservative, number two, many of us don’t want to give up carotid endarectomy to some other practitioners likes cardiologists or radiologists. And number three, the government doesn’t want to pay for a larger cohort of patients.”
Ouriel explained that if carotid artery stenting (CAS) is approved for asymptomatic patients and cardiologists start doing the procedure, they’d be a much larger number of patients treated. The procedure has had Centers for Medicare and Medicaid Services (CMS) approval since March this year, but for a very narrow population – those with a high risk symptomatically greater than 70% stenosis.
“Even though the FDA approves it and the CMS agrees it should be funded, the CMS can set the funding at whatever they want. And it isn’t always based at least initially on any logic. Later on it can be based on what it costs the hospitals to do it, but at least initially it seems more emotion than logic when they set the rates,” Ouriel said.
“Realistically you’re talking only about 5000 patients in the US who are eligible for the procedure, which is not what we needed. It didn’t help, if industry knew that this was going to be the endgame they would never have invested in it.”
Small aneurysms debate
Ouriel also discussed how aneurysms less than 5.5cm should not be left alone – a notion he debated against Professor Roger Greenhalgh at the 27th CX Symposium.
“One of the reasons we don’t treat smaller aneurysms is because the morbidity and mortality of the open surgical procedures is relatively significant,” he explained.
“If you look at the UK small aneurysm trial the 30-day mortality rate was over 5.5%. If more than one in 20 patients die from the procedure it’s sometimes hard to show the benefit of that procedure over observations.
“But that said, the UK small aneurysm trial showed that fixing aneurysms less than 5.5cm in diameter did show statistically significant benefits in terms of survival. The problem is the authors of that study, published in the New England Journal, attributed that benefit not to the procedure but to a greater reduction in smoking.”
Ouriel described his concept as being that if you can treat an aneurysm with a much lower mortality rate – perhaps 1% or 2% – then you can show benefit over observation.
“For instance, taking it to the extreme – let’s say we had a pill that could treat an aneurysm. We wouldn’t wait for that aneurysm to be 5.5cm or even 4cm, anyone who had an aneurysm would be given the pill to prevent rupture and death. But what I would say is let’s think of endovascular treatment as intermediary between the pill and open surgical procedure.”
Other passions
Outside of the clinical environment Ouriel enjoy spending time with his family, and also has a keen interest in sports.
“I like to bicycle, both road and mountain. I like to waterski and, especially, snow ski. The latter is my absolute passion,” he said.
“I have three children, David who is 20 and at Boston University, Ricky who is 17 and in high school, and Elizabeth who is 14 and will enter high school this fall.”
Fact File: Kenneth Ouriel, M.D.
Born
October 21, 1956, Rochester, New York
Academic title:
Chairman, Division of Surgery, The Cleveland Clinic Foundation
Chairman, Department of Vascular Surgery,The Cleveland Clinic Foundation
Education
1973-1977: BA, Biology, BA Psychology, University of Rochester
1977-1981: M.D. with honors, University of Chicago
1981-1982: Internship, University of Rochester/Strong Memorial Hospital
1982-1986: Residency, University of Rochester/Strong Memorial Hospital
1986-1987: Vascular Fellowship, University of Rochester/Strong Memorial Hospital
Academic positions
University of Rochester
1987-1992: Assistant Professor of Surgery
1992-1998: Associate Professor of Surgery
1997-1998: Associate Professor of Radiology: :
The Cleveland Clinic Foundation
1998-now: Chairman, Department of Vascular Surgery:
2002-now: Staff, Division of Radiology:
2003-now: Chairman, Division of Surgery, Cleveland Clinic Lerner College of Medicine of CWRU
2003: Professor, Department of Surgery
2004: Chair, Department of Surgery
Multicenter trial participation:
1993-1996: Co-Principal Investigator, TOPAS Trial – 113 centers
1995-1996: Advisory Board, Iloprost, Stage III/IV Ischemia – 40 centers
1997-1999: Co-Principal Investigator, PURPOSE Trial – 40 centers
1997: Safety Committee, DAG Trial – 40 centers
1998: Advisory Board, Pro-UK DVT Trial – 30 centers
1998: Co-Principal Investigator, PURPOSE-II Trial – 40 centers
Awards and honors:
1976: Phi Beta Kappa, Junior Year
1977: Summa Cum Laude, University of Rochester
1981: Alpha Omega Alpha
1981: M.D. with honors, University of Chicago
1984: Liebig Foundation Award for Excellence in Vascular Surgical Research
1994-1997 Who’s Who in the East, 25th Edition
2001: Honored Member of Strathmore’s Who’s Who
2002: Best Doctors
2002-2004: Honored Member of Strathmore’s Who’s Who
Books authored and edited:
