At Paris Vascular Insights (PVI) 2021 (21–23 October, Paris, France), Peter Schneider (University of California San Francisco, San Francisco, USA) emphasised the need for trainees to learn both open and endovascular techniques in a talk on how to remain skilled in femorotibial/pedal bypass.
Schneider recalled that an “extremely important question” when he was a trainee was ‘how will we learn endovascular?’. A couple of decades later, “the shoe is completely on the other foot,” he said, noting that the question now is ‘how will the trainees learn femorotibial bypass or pedal bypass and/or how will we maintain those skills?’
“Bypass is not disappearing,” the presenter declared, referring to a graph showing a downward trend but then a stabilisation, at least of cases in the USA. Instead, bypass is evolving, Schneider stated. “We are going to more distal targets, we are going after endovascular failure, and we are treating patients with worse disease morphology, and worse tissue damage in the foot.”
In addition to this evolution, Schneider noted that “we know a few things about how to get good results from bypass,” giving the example of better wound healing when there is a bypass targeting a specific angiosome.
“A lot of these things that are coming to a head will be answered by the BEST trial, which is now fully enrolled,” he detailed, also noting that the BASIL-2 trial is currently enrolling in the UK. Anticipating the data that might come out of these trials, Schneider predicts that there will be subsets of patients who are “probably better served with a bypass”.
The PREVENT III trials is “probably the best level 1 evidence that we have”, according to Schneider. This was a randomised trial that included over 1,400 patients with bypasses to the lower leg and foot, showing “quite good” primary and secondary patency, as well as limb salvage.
Turning to the key question of how to remain skilled in bypass surgery, Schneider believes that this should be addressed from a programmatic standpoint that “really depends on the size of your programme and the number of bypasses being done”. He elaborated: “If you get fewer than a couple of bypasses a month, you really have to think about involving more people, having a robust preoperative discussion on the planning so that the trainees and the younger doctors who may not be as familiar with these operations have a chance to understand the thinking, the thought process that goes into success to assess and analyse your complications, and a limb salvage team and conference really helps.”
The speaker told the PVI audience that, in the USA there is an interest in courses, mini-fellowships and proctorships for training. “I think in the early days of endovascular we learned that those things can be effective and now, in attempting to maintain our bypass skills, they are also likely to be effective,” Schneider believes.
In concluding, Schneider considered more generally the role of the vascular surgeon. “One of the things that defines us is our ability to provide both endovascular and open surgery, and we are not going to be very good as a member a multidisciplinary team if we look just like every other member, and I think it is best if we maintain these skills.”
“I just want to curb the enthusiasm,” said Eric Ducasse (Bordeaux University Hospital, Bordeaux, France), opening the discussion following Schneider’s presentation. “By doing endovascular first, for the large majority of patients, we are saving time and treating more and more patients,” he noted.
“Even if you are a very, very strong endovascular-first enthusiast, which I pretty much am, on most patients, there is going to be a group who will fail endovascular, maybe once, maybe twice, maybe every six months for some period of time, and those patients really should be considered if they are still a candidate for bypass, and that is why we need to maintain those skills.”
Moderator Lorenzo Patrone (West London Vascular and Interventional Centre, London, UK) wanted to know Schneider’s opinion on whether chronic limb-threatening ischaemia (CLTI) treatment should be centralised, in line with the trend in aortic care. Schneider expressed caution: “I will say that for every one complex aorta there are a dozen or more patients with critical limb and […] the idea now that you are going to try and limit it even further and funnel those patients to specific centres, it may create more barriers rather than fewer.”
Patrone was also keen to find out his opinion on whether trainees should aim to be either best at endovascular or best at open surgery. “I do not think it is the stripes we wear,” Schneider replied. “I think it is your energy, your enthusiasm, your persistence to learn everything you possibly can. Let us push each other to be the best we possibly can be at all of these procedures and save as many legs as we can.”