Vascular News talks to Dr Rodney White, Professor of Surgery at the University of California Los Angeles School of Medicine, as well as Associate Chairman, Department of Surgery & Chief, Division of Vascular Surgery, and Director of the Vascular Surgery Fellowship Program at Harbor-UCLA Medical Center, about his career in vascular surgery and the future of endovascular aneurysm repair (EVAR)
What made you choose a career in medicine and more specifically, vascular medicine?
“I don’t actually remember the first time I thought I wanted to enter medicine, although I always had an interest in it. My interest in vascular surgery developed at the time I did some research with my uncle at Penn State University. The research related to microporous implants, materials and which had applicability to vascular graft materials. I subsequently continued this research work during my medical school training at Upstate Medical Center in Syracuse New York.”
Did you meet anyone who would have an influence on your career?
“Yes, at Upstate I met Dr Watts Webb, chairman of Cardiovascular Surgery, I worked with him in the clinical service and he supported some of the implant research that I was doing. This eventually lead to a National Institutes of Health RO1 grant during my surgery residency and further developed my interests in vascular surgery.
On a daily basis others have continue to influence my development. Friends and colleagues like Ted Diethrich, Tom Fogarty and Greg Sicard along with many others have had an invaluable influence on my continued development.”
So what attracted you to vascular more than cardiovascular?
“I was more interested in aortic and peripheral vascular diseases than cardiac pathology. I also did not like ‘pump’ procedures which was the primary modality for all cardiac cases at that time. In comparison to the bypass and valve procedures in cardiac surgery, vascular surgery was more exciting and dynamic, particularly from the perspective for potential developments in implants and other therapeutic modalities. This potential continues to be very exciting and dynamic as we see the rapid evolution that is occurring today.
“During my general surgery residency at Harbor-UCLA, Dr Ronald Nelson and Dr Max Gasper, one of the original founders of the Society for Vascular Surgery (SVS), had significant influence on my interest in vascular surgery. I did hundreds of cases with Dr Gaspar’s group when their fellows were not available and this exposure had a great impact on me. Gaspar taught me that vascular disease was a very difficult area that needed a lot of focused training. It was a very stimulating time and is what drew me to peripheral vascular surgery rather than cardiac.”
What have been the proudest moment in your career?
“My proudest moments have been associated with new developments and the rapid evolution of vascular surgical techniques, devices and society activities. I am particularly honoured to be active in the SVS and International Society of Endovascular Specialists (ISES) and the success that these societies have had over the last several years. When I finished my training there was little development in new procedures and techniques. In recent years the vascular surgical community has adapted and evolved to perform new procedures and deal with new technologies. In addition, we have confronted the challenges that go with redefining our sub-specialty to accommodate new methods and technologies. Both societies have confronted and constructively interacted with other specialties over the political and therapeutic issues involved with the evolution of new endovascular technologies. The additional changes associated with the interactions with federal agencies governing and influencing the development and implementation of new technologies has been rewarding. It is most rewarding to see new developments in technology and be able to experience the impact on patient care that has occurred as vascular patients who benefit from the new developments are some of the most grateful patients I have encountered.
“I have been fortunate to be involved with the SVS. The SVS has evolved and offered me the opportunity to do new things and face new challenge, not only in technologies but also in training and redefining the speciality.”
What are your current interests?
“Vascular research including new device development and catheter-based procedures. New endoluminal devices for the aorta, particularly infrarenal and thoracic are focused interested. This involves not only aneurysms but also dissections, penetrating ulcers and trauma. The rapidly evolving imaging technologies, particularly intravascular ultrasound, is another interest. I am also very active in interactions with other specialties and federal agencies (FDA, CMA, AHRQ) concerning training, credentialing, approval, funding and quality assessment for these evolving technologies.”
You have been quite outspoken of the forthcoming Agency for Healthcare Research and Quality (AHRQ) report concerning endovascular aneurysm repair (EVAR). What are your concerns?
“The AHRQ report regarding EVAR is based on data that is available from sources that do reflect the US experience with endografts in high-risk patients. It is very difficult to find peer-reviewed medical literature (level 1 evidence) that reflect what clinical practice ought to be. We do not make clinical decisions by randomizing a patient, if we did we would not need a physician to make clinical decisions. There is always a clinical component to treatment decisions and none of the randomized study models can accommodate the complexities of anatomy, pathophysiology and their impact on medical intervention. When randomized populations are studied most of the patients who are eventually going to be treated are eliminated to satisfy the study design leaving a very small subset of selected patients to randomize. To then use that data to make arguments for patients’ treatments or in this case for reimbursable technology is a flawed philosophy, and it is very hard to combat when the guidelines for data eligible for consideration are governed by selection based on levels of evidence. The SVS Outcomes Committee is developing methods to address this issue and will offer a rational way to consider all relevant components of clinical practice without limiting availability or impeding further development.”
So what effect could this have on the future of EVAR, particularly in high-risk patients?
“If AHRQ’s current unofficial position prevails it could threaten the funding for high-risk patients in the US, which is 70-80% of the US indication for this therapy. It would deny Medicare beneficiaries (high-risk patients) the opportunity to treatment. It would also be very detrimental to further industrial development. A very rapid and developing technology that is still in its infancy needs encouragement from the agencies, not the withdrawal of funding at a very critical stage. It would have a very negative impact.”
What has been the response from the SVS?
“The SVS has adopted the view that it recognises and accepts its responsibility to be the leader in addressing issues related to care of vascular patients. A priority for the society has been development and implementation of outcomes tools not only to provide data on patient outcomes but also to provide appropriate data on which to make regulatory and payment decisions. As the recent carotid and destination therapy decisions from the Centers for Medicare and Medicaid Services (CMS) show, treatment in the future is going to be driven by outcomes assessments. The SVS, with the Lifeline Registry being the original prototype, is focused on compiling credible data in priority treatment areas and adapting currently operational outcomes tools to address specific areas, such as EVAR versus open options, and provide what I think will be the most reliable way to determine an appropriate standard of care.
“The SVS is also making every effort to collaborate with other societies and regulatory agencies, in particular, with the America College of Cardiology and Society of Interventional Radiology, in an attempt to satisfy the need for parity in data collection and analysis.”
How do you relax, if you have any time left?
“I go to the gym every day. I always try to start the day with some physical activity. I like swimming; I try to stay in shape. I have also got four kids who are very active with their lives and they keep me busy.”
Have any of them followed you into medicine?
“My youngest daughter is considering medicine, so we will see what she decides. My youngest son is still in middle school, so he has a way to go. The older children are not in medicine, but they are doing well with their chosen careers.”
Fact File: Rodney A White MD
Born: March 22, 1949 – Punxsutawney, Pennsylvania
1967-1970: Syracuse University (BSci) NY
1970-1974: State University of New York (MD), Upstate Medical Center, Syracuse, NY
1974-1975: Harbor-UCLA Medical Center (Internship) Torrance, CA
1975-1979: Harbor-UCLA Medical Center (Residency) Torrance, CA
1971-1972: Materials Research Fellow, Pennsylvania State University, College Park, PA
1979-1980: Vascular Surgery Fellowship, Harbor-UCLA Medical Center, Torrance, CA
1979-1980: Chief Resident, Department of Surgery, Harbor-UCLA Medical Center
1979-1980: Instructor, Department of Surgery, University of California, Los Angeles
1980-1986: Assistant Professor, Department of Surgery, UCLA
1986-1992: Associate Professor, Department of Surgery, UCLA
1992-2000: Director, Surgery Residency Training Program, St. Mary Medical Center, Long Beach, CA
1993-2004: General & Vascular Surgeon, St. Mary Medical Center
1992-Now: Professor of Surgery, Department of Surgery, UCLA
1980-Now: Chief, Vascular Surgery, Harbor-UCLA Medical Center
1992-Now: Associate Chairman, Department of Surgery and Director, Vascular Surgery Residency Program, Harbor-UCLA Medical Center
Honors and special awards
1969-1970: Phi Beta Kappa
1971-1973: Lange Medical Award
1973: Mosby Book Award
1972-1973: Alpha Omega Alpha
1988: Richard E Weitzman Biomedical Research Award
1994: Best Doctors in America, 2nd Ed, Woodward and White (eds)