From his early days in cardiac surgery through to his professorship in Milan, Italy, Roberto Chiesa talks to Vascular News about various aspects of his career so far. He stresses the importance of being skilled in both open and endovascular techniques, reflects on his proudest professional moments, and discusses his current areas of research.
What led you to pursue a career in vascular surgery?
When I was a young medical student, I fell in love with transplants. In particular, I was struck by the first heart transplantation performed by Christiaan Barnard in 1967 and I decided to enter the world of cardiovascular surgery. The first part of my professional life was spent in the cardiac surgery departments directed by Magdi Yacoub; with him I performed heart and lung transplantations for two years.
Who have been your professional mentors, and what lessons did you learn from them?
The first: Vittorio Staudacher, director of the emergency surgery department at Policlinico di Milano Hospital and Milano University. The second, Edmondo Malan, the first to introduce vascular surgery in Italy. Other mentors are: Jean Michel Dubernard, the first surgeon to perform combined kidney-pancreas transplantation in Europe, and Edouard Kieffer, who was the king of vascular surgery in France. And last but not least, Jo Coselli, who is a good friend in addition to being a mentor, and taught me to perform thoracoabdominal aortic surgery.
How have you seen the vascular field develop over the course of your career?
What I was used to seeing when my career started is completely different to what I see now, 50 years later. The most incredible change was the advent of endovascular techniques and their spread during the beginning of this century. Now, I can offer a chance to a large number of patients who would have been considered unfit for surgery in the past.
Also, some paradigms of treatment have completely changed, including acute type B dissection and thoracic aorta trauma. We were used to treating these urgent conditions with open surgery, with high operative mortality. Today, the approach is endovascular in almost all cases, with really improved outcomes. But endovascular techniques are not a ‘panacea’, and may have significant complications, especially in the long term. I think that endovascular treatment should be performed only by surgeons who can also offter the open surgical counterpart, which means they can decide impartially what is the best solution for every specific situation.
How do you anticipate the field might change in the next decade, and what developments would you most like to see realised?
Certainly, endovascular techniques will continue to evolve, and will obtain even better results for an increasing number of patients. However, I also expect that there will be an upswing in open surgery, in selected situations, and that is why I strongly believe that open surgery must be taught to younger generations. The vascular surgeon of the future will have to know both open and endo solutions for every disease, and be skilled in using and combining them, tailoring their decisions to patients’ needs. Probably also robotic surgery will enter our field, and its principles should be known by future generations.
In the last year, which new paper presentation has caught your attention?
The article “Spinal cord deficit after 1,114 extent II open thoracoabdominal aortic aneurysm repairs,” published by Coselli et al last year in the Journal of Thoracic and Cardiovascular Surgery impressed me.
First, because Jo did a wonderful job, operating on more than a thousand of the worst and most extensive thoracoabdominal aortic aneurysms (TAAAs), with good results. Secondly, because it shows that despite all the efforts of the last 50 years, spinal cord ischaemia remains a high risk and a terrible complication.
What has been the proudest moment of your career to date?
When I was elected as president of the French Vascular Surgery Society (SCVE) in 2013, and president of the Italian Vascular Surgery Society (SICVE) in 2015. We worked hard, with a wonderful group of esteemed collaborators, to improve the participation of young vascular surgeons in the activities of the Societies. One of the changes we made was to increase the number of educational grants for young members. Also, we organised two wonderful national symposia, in Nice for the SCVE in 2013, and in Milan for the SICVE in 2015.
What are your current areas of research?
My main scientific interest has been the surgical treatment of thoracic and thoracoabdominal aortic disease. I became a member of the committee to define the guidelines for thoracocabdominal surgery of the aorta of the SICVE, and member of the writing committee of the descending thoracic aorta clinical practice guidelines of the European Society for Vascular Surgery (ESVS).
Another important objective of my past and current research is the surgical, endovascular, and “hybrid” treatment of diseases that involve the aortic arch, including the ‘frozen elephant trunk’ technique, the ‘arch debranching’ hybrid technique, and the ‘total endo’ arch repair. I was asked to become a member of the committee of experts writing the “Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: An expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS)”.
Vascular graft infections, mainly involving thoracic and abdominal aortic grafts and endovascular stent grafts, represent one of my main historical focuses. I was involved as coordinator of several multicentre studies on arterial homografts for replacement of infected vascular grafts in the treatment of aorto-oesophageal and aortobronchial fistulae, investigating new surgical techniques and performing a systematic review and meta-analysis of the literature.
I am coordinator and principal investigator of numerous trials involving endovascular devices, especially thoracic and thoracoabdominal aortic stent grafts.
My scientific interest in the last decade has focused in particular on the use of dedicated endovascular systems to treat type B aortic dissection, and to the development and improvement of branched and fenestrated thoracoabdominal aortic stent grafts.
What advice would you give to someone starting their career in vascular surgery?
My advice would be: to attend different high-level vascular surgery centres in order to learn both open and endovascular surgery; to read at least two scientific journals every month; and to pull yourself back together when something goes wrong.
What are the biggest challenges currently facing vascular surgery?
The biggest challenges at the moment are total endovascular aortic arch repair, paraplegia prevention during open and endovascular repair of TAAA, and the treatment of vascular prosthetic infections.
Could you tell us about one of your most memorable cases?
A 27cm thoracoabdominal aneurysm in a 34-year old Marfan patient, treated by open repair with a multi-branched Dacron graft and bypass loop for the intercostal arteries, which had a successful course!
How do you like to spend your time outside of work?
My time outside work is very short! But I like to spend this time with my wife Marina, my son Vittorio, our small dog Liz, driving a Porsche 992 Carrera 4S, cycling for more than 100 km, and jogging three times a week.