Although he resolved to avoid a career in medicine as a young man, R Clement Darling III eventually “fell into” the field of vascular surgery. Though it was an unplanned decision, this set him on the path of a long and varied journey into the world of vascular medicine. Speaking to Vascular News, he explained how this came about, how vascular surgery has evolved in his 45-year career, and how his involvement with academic journals, medical societies and ground-breaking research has shaped his professional, and personal outlook.
Why did you decide you wanted a career in medicine, and why in particular did you choose to enter the vascular field?
This is an interesting and complicated question. As many know my father was a well-known vascular surgeon at Massachusetts General Hospital. I worked with him as an operating room (OR) tech and as a vascular lab tech on and off for eight years. One thing I decided after that experience is that I would never go into medicine, I would never go into surgery, and I would never, ever go into vascular surgery. However, after college I went back to being an OR tech and a research technician with Judah Folkman in Boston. As I was trying to figure out what to do with my future, I decided to take some pre-med courses and eventually apply to medical school. My original thought was to be an interventional cardiologist; however, after doing an acting internship in internal medicine, I would rather be tortured than do a career in internal medicine, and so I chose surgery, something I knew and felt I could do reasonably well. I originally wanted to be a liver transplant surgeon. I was going to do a year of vascular to help with the many anastomoses that need to be done in liver transplants and then do a year of liver transplants, but ironically, Dhiraj Shah, my senior mentor, who took me into his vascular fellowship, convinced my wife that it was a stupid idea to do another year of training, and so that is how I fell into vascular surgery.
Who have been your most important career mentors and what wisdom did they impart?
I have had the luxury of working in surgery for 45 years including my time as a technician. I worked with some of the great vascular surgeons, which helped me learn what I wanted to be like and what I did not want to be like. Obviously, my mother and father were strong mentors; my father for his technical skills and my mother for her unique ability to make people feel comfortable and always look at the positive aspects of life. Judah Folkman, Jay Vacanti and Bob Langer in Folkman’s lab were tremendous mentors as far as research and analytic thinking, and Dhiraj Shah, Ben Chang and Robert Leather really showed me the technical and intellectual aspects of clinical vascular surgery. It would be remiss of me not to mention the superb surgeons from the Deaconess such as Roger Jenkins and Frank LoGerfo who fully supported me during my earlier academic career.
What has been the biggest development(s) in vascular medicine during the course of your career?
Again, having a 45-year perspective, the first major development that I was privileged to see was the development of data-driven analytic analysis of the outcomes of bypasses and/or aortic reconstruction. Vascular surgery has pioneered, since the early paper of Linton and Darling, looking at long-term outcomes objectively and critically. Whereas many other fields were writing about technique and anecdotal results of procedures, vascular surgery was one of the first fields that truly objectively analysed their outcomes in order to promote the best vascular care for their patients. I think we need to continue to promote critical analytic thinking in everything we do as vascular surgeons.
This is something that has stayed with me since I was young. Lifetable analysis, five-year outcomes and cumulative patency were instrumental in allowing us to figure out which procedures and operations to offer our patients. I think this has been lost somewhat in the endovascular era. We have reverted back to anecdotal series, but I think with trials like the BEST-CLI trial we will be able to get better and more analytic data. Obviously, endovascular repair of thoracic aneurysms has truly revolutionised aortic surgery, and I think the development of new branch grafts is probably the biggest innovation currently. Although I may be in the minority, I think some of the peripheral interventions still have a significant amount of analysis to go through before we can call them the gold standard.
What is the most interesting paper or presentation that you have seen recently (aside from your own research)?
I think much of the new stratification of wound, ischaemia and foot infection (WIFI) will be extremely important in the future of evaluating peripheral bypass and intervention. For many years we have lumped critical limb ischaemia in as one pathology; however, as most of us know (especially if you deal with a lot of peripheral wounds) rest pain and shallow ulcer are radically different processes than extensive forefoot gangrene and foot sepsis. I think the WIFI criteria that we have seen from papers from Joe Mills and Sidawy and further analysis by Schermerhorn and Jeremy Darling, which really opened our eyes to how we can objectively analyse what will work and what will not, and I think this should lead to tremendous improvement in patient care. Also, I think much of the work with aortic dissections will help us finally create a reasonable algorithm for this challenging disease. I still think it is debatable whether type B dissections should be treated medically or endovascularly but I think much of the work by Christoph Nienaber has been fascinating and this is a new area where we will see a tremendous amount of progress.
What are your current research interests?
The Vascular Group in Albany has been recognised for objectively evaluating our outcomes. Much of our work now is done in database and clinical management as well as analysing whether regionalisation would optimise outcomes, especially for large rural areas. Many of our future projects revolve around outcomes and cost analysis, especially in regard to peripheral intervention of peripheral bypass. We still do a significant amount of bypass surgery in Albany, mainly because of our ability to work with many of our “competitors” such as interventional cardiologists who have allowed us to take care of many of their most difficult patients.
The BEST-CLI trial is currently ongoing; as a Principal Investigator, how do you think its results will affect lower limb revascularisation treatment?
The BEST-CLI trial offers us the ability to objectively analyse results of bypass surgery vs. peripheral endovascular therapy. I think it will not only give us some conclusions but also open up many questions. One of the concerns my group has is that open distal bypasses may be becoming a lost art. Although we still do over 400 distal bypasses a year, many institutions do less than 10. We strongly believe that a balanced approach of endovascular and open bypass currently offers the best limb salvage for many of these very difficult patients and then maybe in the future we will need fellowships in order to re-teach distal reconstruction much like we did in the 80s and 90s for in-situ bypass. But I think the BEST-CLI trial is an excellent trial that we all should promote as much as possible and try to enrol as many patients as possible because when we look at each patient individually, many of us think we know what the right answer is but without objective data we will not be able to analyse this correctly.
How has your long involvement in the editorial process of many vascular academic journals affected your career and professional outlook?
Evaluating much of the new literature offers many of us the ability to see how people think differently around the world. Having been working and operating for 45 years, the workings of the operating rooms really have not changed, but I think the thought processes of the surgeons—especially vascular surgeons—has changed dramatically over these years. By having the honour of being allowed to review the literature, it helps me get perspective on how people are thinking, what procedures are being done, and what some of the young scientists are doing to solve these very difficult problems.
As President-Elect of the Society for Vascular Surgery (SVS), what are some of your main goals for your Presidency?
As President-Elect of the SVS, one of my main goals is to bring the team concept of vascular care to the forefront. Again, having worked as a tech, medical student, resident, fellow, and attending over almost five decades, I have had the luxury of seeing that taking care of vascular patients requires a multidisciplinary team effort. This should not be solely physician-centric but should also be cognisant that we could not do what we do without well-trained vascular nurses, expert vascular technologists in the vascular lab and the angio suite, and the help of administrators to make our practices hum and create an infrastructure and environment that will allow us to treat the most complicated patients. Without their help, expertise and concern we would not be able to accomplish what we have accomplished over the past 50 years.
We need to concentrate on providing a wholly complete vascular service to our patients, our third party payers and to our institutions; this will set us apart from many of the other specialties who work in vascular care. Also, since most of our patients have significant comorbidities, we really need the help of cardiologists, diabetologists and others to optimise care. Two-thirds of the SVS members work in non-academic institutions. I also think it is therefore important that the society makes sure that it understands the concerns of our constituency in these non-academic centres and prepare academic and non-academic vascular surgeons for the future in regard to how we are going to be paid, which patients are going to be treated, and how we can work with hospitals and third party payers to provide the best care. Lastly, we have to continue to promote and brand vascular surgery. As a second-generation vascular surgeon, it is still mind-boggling that many of my family do not understand what we do, let alone the public. By continuing to promote vascular surgery as the complete specialist in vascular disease, we can separate ourselves from our general surgery and cardiac surgery origins and promote the uniqueness of our specialty.
What are some highlights that we can expect from the SVS Annual Meeting in 2017?
Ron Dalman has done a superb job with the SVS annual meeting. This is going to be interactive, informative, and not just academic. There will be many hands-on sessions, there will be sessions on practice management and we will also have sessions that will bring in the Society for Vascular Nursing, the American Venous Forum, The Society for Vascular Ultrasound and the Vascular and Endovascular Surgical Society. Again, I think by creating this team approach we will be able to have a vibrant, exciting and informative meeting for those involved in academic vascular surgery, as well as those working in community practice.
Could you tell us about one of your most memorable cases? What did this experience teach you?
When someone is in this field for a long time, there are a lot of cases you are proud of and some that still haunt you from their complications. Having an interest in complex aortic reconstruction, one can always fall back on that as it is one of the few procedures that needs meticulous preoperative planning, is time dependent, and will not tolerate mistakes. However, I will have to say some of the new approaches, such as those written up by Gib Upchurch using a hybrid approach to repair the proximal descending thoracic aorta endovascularly and then performing a type IV open reconstruction off of the endograft, re-emphasised to me that a combined hybrid approach is mandatory for vascular surgery. However, I would have to also mention when Dhiraj Shah brought back the eversion endarterectomy technique from Europe to our group and we all thought it was foolish. Obviously, we have now adapted it as our “go-to” procedure for carotid endarterectomy. It was important to see that even senior surgeons can change their approach, especially when they evaluate analytically and intellectually and that the results can be as good, if not better, than the prior technique. This demonstrates to me, not so much about the technique, but about the way vascular surgeons are willing to change what they do for the benefit of the patient much like they have done in adopting endovascular therapy.
What are some of the proudest moments in your career?
The proudest moment so far has been the recognition of our group as not only a group of men and women who do excellent clinical vascular work, but one that has changed the approach that many systems use to work in a supportive group incentive environment. I grew up in a system that was very internally competitive and I vowed not to live in that environment. I am proud that we have been able to create a strong family-like supportive group of tremendous vascular surgeons in Albany. My children make me the most proud. My truly proudest moment was watching my son Jeremy, who works in Mark Schermerhorn’s incredible clinical lab at the Beth Israel Deaconess, present at the Society for Vascular Surgery and the Society for Clinical Vascular Surgery. It is great to see his passion, preparation, and determination to do well. As a father and a vascular surgeon, that made me very proud.
What three questions in vascular medicine still need to be answered?
For patients with significant critical limb ischaemia with foot sepsis and significant tissue loss, we still do not know what the best initial therapy is—hopefully the BEST-CLI trial can help us delineate this. Our bias is that distal bypass provides more direct flow than some of the interventional techniques, but I still think that we need to iron out what the contributions of the angiosomes are, how many vessels to reconstruct, and whether bypass directly to the affected area or peripheral intervention is the optimal therapy.
Obviously, in carotid disease I think we need to have a better handle on what patients are asymptomatic and symptomatic. Many of the patients who are “asymptomatic” have silent infarcts and still plaque morphology is something that needs to be completely evaluated. It needs to be more aggressively investigated as I think this will be a key to which patients to treat and which patients to treat medically. I think the concept of treating all asymptomatic patients medically is still more nihilistic than scientifically based.
Ideal treatment and ideal timing of treatment for aortic dissections is a fascinating topic that we are just scratching the surface of right now. I think that is an important question to be answered as, at least in our practice, we see more dissections than we see aneurysms.
What advice would you give to young vascular surgeons starting out in their careers?
I think young surgeons have a tremendous opportunity; the field is much more varied and broad than it was when I started. Vascular surgery is a field like no other. The breadth of expertise that we can provide continues to expand. Our trainees are much smarter than we were when we started, and now we can actually expect to lead a reasonable life in our practice.
I think it is important for the young vascular surgeons to find out what they like in vascular surgery; what they feel they do well, and find out how they want to structure their practice in life. In my era we all expected to stay at one job for the rest of our lives. Today, young surgeons should use their first two to four years to be at a relatively high-volume, low-stress system where they are not asked to develop a practice but more to perfect their technique and their skillset. Those surgeons starting out need to be patient and really figure out what makes them happy and what motivates them to do their best. Having these few years to be able to have some self-reflection as well as see how the breadth of vascular surgery is very important for them. Although they may not believe it, I think getting a job that can offer this is more important than making more money in your first job.
What are some of your hobbies and interests outside of medicine?
My family is my number one hobby. I love to travel with them, for example to the beach and Martha’s Vineyard, and especially to Disney even though my three kids are all grown. It is great having grown children now who are your peers as much as they are your kids. I always enjoyed skiing, playing tennis and sailing and travelling with my wife Julie and our friends.
2009–present Director, The Institute for Vascular Health and Disease, Albany, USA
2004–present President and Partner, The Vascular Group, Albany, USA
1998–present Chief of Division of Vascular Surgery, Albany Medical Center Hospital, Albany, USA
1991–present Attending Surgeon, Albany Medical Center Hospital, Albany, USA
2001–present Professor of Surgery, Albany Medical College, Albany, USA
Education and training (selected)
1978 BS, Trinity College, Hartford, USA
1984 MD, University of Cincinnati Medical College
1984–1988 Assistant Residency, Harvard/Deaconess Surgical Service, Boston, USA
1988–1989 Chief Residency, Harvard/Deaconess Surgical Service, Boston, USA
1990–1991 Vascular Fellowship, Albany Medical Center Hospital, Albany, USA
Editorial positions (selected)
1999 Editor, Annals of Vascular Surgery
2002 Editor, Vascular and Endovascular Surgery
2008 Editor, Annals of Vascular Diseases
2013 Editor, The Indian Journal of Vascular Surgery
2015 Co-Editor and Author, Master Techniques in Surgery: Vascular Surgery (2 volumes)