Ross Naylor, Professor of Vascular Surgery, Department of Cardiovascular Sciences, University of Leicester, and consultant vascular surgeon, Leicester Royal Infirmary, Leicester, UK, developed his interest in carotid endarterectomy back in 1979. Since then, he has published over 300 papers and book chapters on cerebral vascular disease. In this interview with Vascular News, Naylor spoke about his career, controversies in carotid intervention, new technologies and objectives for his term as president of the Vascular Society of Great Britain & Ireland 2011–2012. He also described his hobby of road cycling…
How did you come to choose medicine as a career and why vascular surgery?
I am embarrassed to admit that (aged 14) I decided on a medical career whilst sitting in my school Careers Office. I had been told to attend with clear ideas about my future, but had done absolutely nothing. I saw a brochure entitled “Why don’t you be a Doctor” and that was that! I was a third year student when I decided on surgery (loved the buzz and activity) and fourth year when vascular chose me. I had just watched someone open an abdomen and clamp a ruptured aortic aneurysm in what seemed like seconds and thought “that’s for me”! I have never regretted it.
Which innovations in vascular surgery have shaped your career?
Improvements in medical therapy, the rise of evidence-based practice and the endovascular revolution. As a trainee in the 1980s, no one ever envisaged that aneurysm repair could almost become a day-case procedure.
Who were your mentors and what advice of their do you still remember?
Jetmund Engeset (Aberdeen) saw potential in the student who frequented his ward late at night and nurtured my fledgling research interests. Second was Vaughan Ruckley (Edinburgh) who showed me you could be a busy NHS surgeon, still produce influential research and become a highly respected professor. Peter Bell (Leicester) influenced my career (both clinical and research) more than anyone else and was singularly influential in persuading me to return to Leicester in 1995 after I had moved back to join Jetmund in Aberdeen as his consultant colleague in 1993.
Carotid endarterectomy is your main area of interest. How did you develop this interest? Do you still remember the first carotid procedure you performed?
In 1979, I asked Jetmund to recommend a topic for my final-year student elective and he suggested a controversial operation called carotid endarterectomy, which was apparently popular in the USA but rarely performed in the UK. It was the beginning of a career-long interest and despite having published 300+ papers/book chapters on cerebral vascular disease, I still find the subject both fascinating and enduringly controversial. I cannot remember my first operation, but I do recall my fourth or fifth. We had just introduced the quality control programme in Leicester, where we inspected the inside of the endarterectomy zone with an angioscope before restoring flow. Peter Bell was supervising me when the ‘scope revealed a large luminal thrombus. Having previously been sceptical about the merits of the project, he was a rapid convert and (21 years later) we still use angioscopy for completion assessment.
You advocate early intervention in symptomatic carotid stenosis patients after the first onset of symptoms. Have you seen any changes in clinical practice in recent years or are some physicians/decision makers still resistant to this idea?
Yes and yes! It is indisputable that the risk of stroke is highest in the first few days after onset of symptoms and that the longer you delay endarterectomy, the less the benefit conferred to the patient. After many years of promoting the need to intervene early, this is now a key component of the ESVS Guidelines and I am pleased that countries around the world are actively changing the way they prioritise transient ischaemic attack/stroke patients. Sweden now has a median delay (symptom to surgery) of 12 days. In the UK it is 15. Yes, there are still those who close their ears to the evidence, but that will change. I suspect most surgeons/interventionists (if asked) would want to be treated as soon as possible after onset of symptoms. Shouldn’t we offer the same service to our patients?
At the recent CX Symposium, 61% of the delegates backed you and agreed that “Randomised controlled trials for asymptomatic carotid disease without a medical arm will be obsolete when published”. One of your arguments was that the trials showed that over 90% of the interventions in asymptomatic patients are “ultimately unnecessary”. What is your key message on this subject?
The world has moved on since ACAS/ACST recruited patients, but despite compelling evidence that the annual risk of stroke on medical therapy is declining (also observed in ACAS and ACST), ACAS data from 1995 are still being used to model risk-benefit analyses in contemporary guidelines. No one is seriously suggesting that all interventions should cease, but we do need to identify a smaller cohort of “high risk for stroke” patients in whom to target surgery or stenting. Accordingly, randomised trials comparing carotid endarterectomy with stenting that have not included a medical limb face the unfortunate prospect of being criticised following publication. It is no use hoping that lower procedural risks will greatly increase the benefits of intervention so as to overcome the lack of a medical arm. Even if you could operate (or stent) with a 0% risk, 93% of interventions would still be unnecessary.
CREST continues to generate a lot of debate, with various interpretations with regard to endpoints. At CX, the audience voted against (93%) swinging the practice towards carotid artery stenting. Do you forsee a swing towards stenting in the future?
If this had been a cardiology/radiology audience, the result would have been different! It is inevitable that stenting will assume an increasing role, if only because the indications for stenting in “average risk” patients were liberalised in the 2011 American Heart Association Guidelines. One consequence of CREST has been the debate about the inclusion of perioperative myocardial infarction in the primary endpoint. The popular interpretation of CREST was that perioperative myocardial infarction was associated with poorer long-term survival, but at the 2011 VEITHsymposium, Tom Brott (CREST principal investigator) stated that “it was a myth to say that myocardial infarction in CREST had a bigger impact on late mortality than did perioperative stroke”. Without the inclusion of perioperative myocardial infarction, surgery would have been statistically superior to stenting in symptomatic patients. My personal opinion is that the myocardial infarction issue has distracted attention from the much more clinically important goal of rapid treatment. Only 13/2,500 patients (0.5%) in CREST died prematurely following procedural myocardial infarction (seven following endarterectomy, six following stenting). This must be compared with evidence that up to 10% of patients will suffer a stroke within seven days of their index transient ischaemic attack. For now, surgery is probably the safer intervention in the hyperacute period for the majority of centres, but stenting will assume greater importance as delays increase. Of course, some interventionists may be able to offer comparably safe interventions in the hyperacute period and stenting is then entirely appropriate. However, it remains to be seen just how generalisable that might be for practice as a whole.
It is still controversial whether carotid stenosis patients undergoing coronary artery bypass graft surgery should undergo carotid intervention. What is your opinion on this matter?
How long have you got? Having been an advocate of synchronous carotid/coronary procedures, I began to harbour doubts about its role in neurologically asymptomatic patients, who make up >90% of those being considered for intervention. There is now a growing body of evidence that the vast majority of peri-operative strokes after coronary bypass (perhaps 95%) cannot be attributed to a previously asymptomatic carotid stenosis. Most probably follow atherothrombotic embolism from the aortic arch. My own practice is to offer synchronous carotid/coronary revascularisation to the very small cohort of recently symptomatic patients who (because of their cardiac status) cannot undergo isolated carotid surgery. I would also offer a synchronous procedure to patients with bilateral severe asymptomatic disease (<2% of those undergoing cardiac surgery). We do not offer synchronous procedures to anyone with a unilateral severe asymptomatic carotid stenosis.
Can you describe a memorable case?
Six years ago, I was asked to see a lady in our Nephrology Unit. Ten days earlier, she had presented to another hospital with anuria. Investigations showed she had occluded her aorta from the iliac bifurcation up into the mid-thoracic region (normally a fatal event). Every time she dialysed, she developed mesenteric ischaemia. If dialysis was withheld for any length of time, she suffered flash pulmonary oedema. Our anaesthetists advised that she would not survive a major thoraco-abdominal reconstruction and when she suffered a more severe episode of mesenteric ischaemia, I and my colleague Rob Sayers performed a left axillo-superior mesenteric artery bypass which resolved her symptoms. We subsequently performed a right axillo-bifemoral bypass and she has since undergone successful renal transplantation. You just never know what is going to come through your door!
What are your other current topics of research in cerebral vascular disease?
Three projects. The first examines public awareness of the need to present early after onset of stroke/transient ischaemic attack symptoms. We have shown that while 90% are aware of the FAST symptoms (Facial weakness, Arm weakness, Speech problems), only 50% know that leg weakness and visual loss are important warning symptoms. The second looks at the interaction between biomarkers, gene profiling studies, plaque histology and computerised plaque analysis in patients undergoing hyperacute carotid surgery. The third is my latest attempt to study the pathophysiology of post-endarterectomy hypertension. Anyone who has tried to do this in the past will know just how difficult this is.
What do you hope to achieve as 2011–2012 president of the Vascular Society of Great Britain & Ireland?
I was honoured to be elected president for 2011–2012. This is an exciting time for UK vascular surgeons as we secured independent specialty status through an Act of Parliament on 16 March 2012. Our absolute priority is to ensure that the 20 trainees selected to enter the new national programme each year from 2013 receive targeted high-quality training, free from the rigours of covering general surgery. This will, of course, involve a closer working relationship with our interventional radiology colleagues and I look forward to that. In Leicester, our interventional radiology colleagues have (for some years now) provided our trainees (and visiting fellows) with high-quality interventional/endovascular training which has been much appreciated.
Which new techniques and technologies will you be watching closely in the future?
Innovative new methods for delivering medical therapy, totally endovascular solutions for the aortic arch, the emergence of nanotechnology, bioabsorbable implantable devices and a desperate hope that someone will finally tell me which acute thoracic aortic syndromes actually “need to be treated” rather than “can be treated”.
What are your interests outside of medicine?
Skiing and road cycling. After turning 50, I realised I had to stop finding excuses and get fit again. My wife had already taken up road cycling and I joined her. It was very hard to keep up with her to begin with, but I have now tackled Mount Ventoux (securing Jean-Pierre Becquemin’s respect), Alpe d’Huez and the Col d’Izoard. My target this year is the Stelvio Pass in Italy with its 48 hairpins.
- Chapelpark Primary, Forfar, Scotland, UK
- Merchiston, Edinburgh, Scotland, UK
1976–1981 Medical school, Aberdeen University, Aberdeen, UK
1981 MB, ChB with commendation, Aberdeen University
1986 Fellow of the Royal College of Surgeons of Edinburgh
1990 MD, Aberdeen University
1994 Certificate of Higher Surgical Training
1996 Fellow of the Royal College of Surgeons of England (ad eundem)
1981–1982 House officer, Aberdeen Teaching Hospitals
1982–1983 Lecturer in Pathology, Aberdeen University
1983–1985 SHO in Surgery, Aberdeen Teaching Hospitals
1985–1988 Surgical registrar, Edinburgh Teaching Hospitals
1988–1990 Research fellow, Edinburgh University
1990–1991 Surgical registrar, Kirkcaldy
1991–1993 Lecturer in Surgery, Leicester University
1993–1995 Consultant vascular surgeon, Aberdeen Royal Infirmary
1995–current Consultant vascular surgeon, Leicester Royal Infirmary
2002 Reader in Surgery
2002 Hunterian Professor of Surgery (RCSEng)
2003 Professor of Vascular Surgery
2000–2005 Editorial Board; The British Journal of Surgery
2003–2008 Editorial Board; The Journal of Vascular Surgery
2006–current Council member, Vascular Society of Great Britain & Ireland
2006–current Editorial Board, European Journal of Vascular & Endovascular Surgery
2007–2010 Associate editor, European Journal of Vascular & Endovascular Surgery
2010–current Council member, European Society of Vascular Surgery
2011–2014 Senior editor, European Journal of Vascular & Endovascular Surgery
2011–2012 President, Vascular Society of Great Britain & Ireland
2011–2012 Council member, Association of Surgeons of Great Britain & Ireland
2012 Voted winner of “Pioneer in Performance Award for Europe”