From fenestrated grafts, new medical devices and patents, Roy Greenberg, Cleveland Clinic, Cleveland, USA, is now also au fait with the Wii and talking about Pokemon, thanks to his children. He told Vascular News all about his fascination with human physiology, imaging, and fish tanks!
When did you decide you wanted a career in medicine and has it lived up to expectations?
The first memory I have of wanting to be a doctor was at the age of six. I do not think I knew why I wanted to be a doctor at that point, but I realised that I had a strong interest in medicine. However, the focal aspects of my interest in medicine have certainly changed over the years. I would say that during college, medical school, residency and my career, I have fostered a great fascination with human physiology, imaging technology and engineering devices. It has been a great joy to use these interests to develop new treatments that will hopefully improve the quality of people’s lives.
Why did you decide to specialise in vascular surgery?
Well, this decision was subject to a bit of coincidence. My first rotation as a resident was on the vascular surgical service with Drs DeWeese, Green and Ouriel at the University of Rochester. I remember my very first day of internship, Dr Ouriel quizzing my on some angiographic studies and I was so proud of my ability to answer those questions. After that, they really cultivated my interest in diseases of the blood vessels. This area of pathology fit in nicely with my interest in imaging and also in device design. The cumulative effect was that of a snowball going down a mountain just gathering momentum and size in the process. It was really after my first month of internship that I knew that I wanted to go into vascular surgery and to be honest I have never looked back since that time, or regretted that decision.
On a professional level, what have been your proudest moments?
I consider my proudest moments from a patient care standpoint are when we are developing a new technique or using a new type of device, and we have a successful outcome. Especially when you sit and think about what the alternative method of treatment would have been for that patient. For example, the first complex thoracoabdominal aneurysm we fixed with a branched graft was in a patient that suffered two cardiac arrests during anaesthetic induction for attempted open repair. The advice provided by cardiology at that time, was not to use anaesthesia during his thoracoabdominal aneurysm repair. It is really enjoyable when the patients appreciate this as well, although often patients do not have a comprehension of what the alternative treatments are like.
Another proud moment occurred this year when I received recognition from my peers as to my accomplishments in medicine. I was awarded the Sam and Marie Miller Master Clinician Award which is given to one physician a year from the Cleveland Clinic who has demonstrated excellence in clinical medicine. Now, the Cleveland Clinic is an institution where it is very easy to be a good clinician. You just have to know what other good clinicians you can call when you have a problem. But, to be singled out by my peers at this institution was both touching and meaningful and on a professional level, means much more than any title that I might earn after my name.
Finally, from a research standpoint, one of my proudest moments is when I was able to work with my father and one of his graduate students named Vikash Goel, to the point of having a joint patent and two papers published. It was very gratifying to see both of our names in print in good journals, and on a patent, irrespective of the ultimate value of the endeavour.
Vascular surgery has undergone many changes over the years – what do you think the most fundamental changes have been?
Well, I would not characterise myself as a senior vascular surgeon yet. I really grew up with endovascular being a part of vascular surgery. In fact, I have very strong memories of arguments during my residency and fellowship training in Rochester about endovascular vs. open surgical therapeutic options. These arguments still go on, on a day to day basis, although the people have changed. But clearly, the technology that was once so cantankerous has become much more broadly accepted. I would say that the fundamental changes of vascular surgery are yet to come, and will involve a greater appreciation for non-invasive imaging, cross-sectional imaging techniques, tissue characterisation and molecular genetics. Vascular surgery has certainly been one of the few specialties that has embraced change rapidly and has been able to morph itself to accommodate these new ideas and philosophies. I hope that in the years to come, we can all watch the field of vascular surgery continue to evolve into a specialty that has even fewer boundaries and more potential for significant changes in medicine.
Your professional training includes a fellowship in interventional radiology. What influence did it have on your career?
Interestingly, when I was a general surgical resident, I had asked to have some dedicated training in interventional radiology. At that time, this concept was not met with great enthusiasm. I had been following the career of Mike Dake over the years, and approached him to see if further training under his guidance was possible. That never really worked out, and when I returned from a visit with Dr Dake, I was greeted by Dr Green and Dr Seymour Schwartz at the University of Rochester who had met with the folks in radiology and offered me the opportunity to do a fellowship there in interventional radiology. This training was critical to my medical education. It was really the detailed disciplined training of learning radiology from the standpoint of ultrasound, computed tomography, magnetic resonance and interventions during that year that honed my skills to allow me to have a different perspective of how patient care should be provided in vascular surgery. This became particularly apparent when I went to Malmo, Sweden to train with Dr Krassi Ivancev and Dr Bengt Lindblad. In Malmo I received an opportunity to both observe and participate in levels of care and interventional procedures that I had not thought existed anywhere at that time. So I would say that my radiology training had as much to do with my professional career as my surgical training. It is really the mix of both, understanding radiology and understanding patient care that provides me with a sound foundation for making clinical decisions and also developing research concepts.
You have a number of patents registered. Which of them has had the greatest impact in the treatment of vascular disease?
This is a hard question, because you really never know how valuable patents are until many years after they are issued, and it also depends a bit on how you define vascular disease. I actually think my most significant patent, is a patent that relates to heart valve treatment. And it does not stray far from concepts involved in endovascular grafting. The heart valve technology that is existent to date relies on stents and valves and somehow they are attached together. And the technology that I had developed here, and that we have implanted in one patient, involves the separation of the concepts of fixation, sealing and annular function. How those three concepts meld together into a device are the subject of a patent that I hope will have the greatest impact on the treatment of patients with cardiovascular disease. My patents on branched graft technology, delivery systems, collaborations with people like David Hartley, Michael Lawrence-Brown, and Timothy Chutter, I think will all have significant impact, but clearly relate to a smaller segment of the population than those with valvular heart disease.
How do you see the performance of fenestrated grafts, one of your areas of research?
Fenestrated grafts are one method by which aneurysm that involve or abut visceral vessels can be treated. Although initially this was met with some scepticism, we now have seven- and eight-year follow-up data on our early patients that show the technique to be surprisingly durable. Ultimately I think it makes sense to look at a computed tomography scan and determine where the aorta is healthy, and where the iliac arteries are healthy and repair any disease from one healthy segment to another healthy segment, irrespective of what branches come off in the intervening segment. That mandates that these vessels be incorporated into the repair with the use of either fenestrations or branches. Fenestrations are not conceptually an optimal means of accommodating a branch, but they solve some fundamental problems that branches cannot. For example, they take up very little space, they are relatively easy to align, and devices that incorporate fenestrations can be loaded in fairly small delivery systems. I think the true test of fenestrations will be when the technique is disseminated to treat patients with these complex aneurysms. Ultimately I think this is going to be more successful than others believe largely because of advances in imaging technology that will make this operation simpler. No longer will people be forced to think in three dimensions because we will be able to display angiograms, and during operative procedures, view the anatomy in three dimensions real-time.
Tell us about the most memorable case you have ever treated?
It is very hard to narrow that down to one case. I have one patient that I followed for many years, who presented in extremis with an aortal bronchial fistula, ultimately requiring extracorporeal membrane oxygenation simply to keep him alive. The aortal bronchial fistula formed after several operations for childhood coarctation. We were able to treat this with a stent graft and after 5–6 days wean him off the echmo, treat him with antibiotics for a number of months, as his lung abscess regressed, and watch him return to health and relatively normal lung function. Over the years I have become friends with him and his wife, and gotten to know a little bit of their family, and consequently, he is a very memorable case. I have other patients like that too. A number of patients with connective tissue diseases who are quite young, and are referred because they really do not have any other options in terms of treatment. Some of those memorable cases have really nice outcomes, and some of them are the saddest cases that I have ever been involved in. But I guess it is the challenge of those cases that makes this area of medicine the most rewarding.
Who are the people who have influenced you and what advice of theirs do you always remember?
I think my father had the biggest influence on how I think. He has always approached things with an engineering prospective, and it used to drive me crazy when I was a child and he would help me with math homework. We would always have to go back to the very basics, but now, I realise it is the very basics that are the most important. And I will not forget the people that really taught me a lot of the surgical techniques that I use today on an everyday basis, like Drs Green and Ouriel, training us on the use of sharp dissection instead of blunt dissection, and how important exposure was with respect to vascular surgery. Proper exposure and the set-up of the field is probably one of the hardest things to train fellows today. And I have to credit Dr Ivancev with several pieces of advice that include two very memorable sayings. The first is “pay attention to the very small details, because it is the very small details that make a difference”, and that is clearly true in endovascular surgery as well as vascular surgery. And the second, which is something that many people laugh about, but is really true, is that “when you are nervous during a procedure, give the patient more heparin”. Ironically, this is one of the fundamental differences between vascular procedures and most other procedures, and I find that the fellows coming into our programme take a little while to learn this. It is true from an endovascular prospective because we have catheters and sheaths sitting in arteries for longer periods of time, and it is true from an open perspective because significant bleeding always results in a clamp somewhere, and then you do not want to propagate that problem with more clotting, so I have to tell Krassi that he is right. If you are nervous, I would give more heparin. I would also have to say that Dr Norman Hertzer had a significant influence on me in terms of doing research as I saw him spending countless hours going over his cases and results. I learned his underlying philosophy that “outcomes matter”. I hear myself saying it over and over again. And I would say that there is one more person that had a lot of influence on me, and that would be Dr Ed Bevin. And although I cannot put a single line or saying to crediting Dr Bevin with his methods of treatment or surgical techniques, it is his overall attitude that influenced me. He had a calm demeanour and appeared to be immune to political issues, allowing him to always put the patient and the individuals’ interests of concern as the primary priority.
What are your current areas of research?
Well, they are really just evolutionary changes of my past areas of research which include developing devices that are used to treat cardiovascular problems, developing imaging techniques that can be used to facilitate diagnoses and implantation of these devices, and the analysis of clinical results. Unfortunately, it is getting more and more difficult to do clinical research, at least in the United States. However, I hope that this pendulum swing reverses, because it is the clinical research and as Dr Hertzer says “outcomes analysis” that makes the biggest difference. I think that our research patients probably get better treatment than other patients because their progress and complications are so heavily scrutinised. But I also think that we have learned from our mistakes. Without paying careful attention in a systematic manner to our outcomes, we will not learn from our mistakes.
Outside of medicine, what other interests do you have?
Well, I have to say my primary interests outside of medicine are my family. My wife Alicia, and my two kids Zachary and Lucas. I love spending time with them and look forward to showing them how small the world we live in really is. I have actually become quite proficient at things that are common in 5- and 7-year-old conversations, such as Pokemon and playing the Wii, in addition to soccer and T-Ball. I used to do a lot of diving, but since having children not of diving age, I have become more of a true fair weather diver, and have a lot of fish tanks. They provide me a great deal of enjoyment both to look at and learning about all of the details of how to keep fish and corals. I also like the outdoors, including camping, hiking and biking. And I have to say that I really do enjoy traveling. I think that the world is a small place, and it has been getting much smaller as you develop friends in more and more countries. I find that my primary objective on a lot of trips has focused less on the specifics of a conference, but more in seeing the colleagues that over the years I have gotten to know.
Roy Kenneth Greenberg
Place of Birth: Ithaca, NY, USA
1992 MD, University of Cincinnati College of Medicine, Cincinnati, Ohio
1987 BA, Cornell University, Ithaca, NY
July 1999–Present – Cleveland Clinic Foundation, Staff
Departments of Vascular Surgery, Cardiothoracic Surgery and Biomedical Engineering
Associate Professor of Surgery, Cleveland Clinic Lerner College of Medicine
Director of Endovascular Research and Peripheral Vascular Core Laboratory
American Board of Surgery, certified 15 November 1998 – Recertified 1 December 2008
American Board of Surgery in Vascular Surgery, certified 15 May 2001
Medical licenses and certificates
1999 State of Ohio License
1992 State of New York License
2004 State of Michigan License
June 1998–June 1999 Fellow in Vascular Surgery, The University of Rochester, Division of Vascular Surgery, Rochester, New York
January 1998–May 1998 Endovascular Fellowship, Lund University/Malmo University, Department of Radiology, Malmo, Sweden
1997–1998 Fellow in Interventional Radiology, Instructor, Vascular Surgery, The University of Rochester, Division of Vascular Surgery
1996–1997 Chief resident, Instructor in Surgery, The University of Rochester, Department of Surgery
1992–1996 Intern, resident, and instructor in Surgery, The University of Rochester, Department of Surgery
Distinguished Fellow Society of Vascular Surgery (Clinical Trial and Technology Board, Lifeline Registry Outcomes Board, Outcomes Analysis Board, and Annual Meeting Program Committee), fellow of the American College of Surgeons, fellow of the American College of Cardiology, fellow of the American Association for Thoracic Surgeons, member of the Peripheral Vascular Surgery Society, member of the Society of Interventional Radiology, Midwestern Vascular Surgical Society (Chairman, Membership Committee), Ohio Chapter American College of Surgeons, and International Society of Endovascular Specialists.
Books and editorial activities
Editor – Atlas of Endovascular Techniques. WB Saunders. In progress.
Associate Editor – Abdominal Aortic Aneurysm Stent Grafts: The First Decade and Beyond. Futura Publishing Company, NY. In Press.
Section Editor – Multidisciplinary Studies. The Rochester Manual. Laennec Publishers. 1996.
Editorial Boards: Journal of Endovascular Therapy, Annals of Vascular Surgery, Cardiovascular Surgery, Endovascular Today, ISMICS/Innovations. Reviewer: Journal of Vascular Surgery, Journal of Endovascular Therapy, Journal American College of Surgeons, The Lancet, Circulation. Guest editor: Seminars in Vascular Surgery (June 2009, Long Term Durability of Aortic Repair), Seminars in Vascular Surgery (June 2007, Aortic Diseases), Saunders Atlas.
134 published manuscripts, five manuscripts in press, and three submitted
30 book chapters published, three chapters in progress, and five in press
21 awards and honours
10 cardiovascular summits organised
16 US patents
Five physician sponsored investigational device exemption studies