We can honor the past without living in it

Malachi Sheahan III, MD, peels back the layers on why a decision by the Southern Association for Vascular Surgery (SAVS) to replace its signature emblem is the right one

Imagine you are considering moving to a country where you will be an ethnic minority. For example, suppose I am contemplating a position at a hospital in Ghana. I would spend a lot of time thinking about how my family and I would fit in with the cultures of that nation. How would we be perceived by its population? Suppose, in my research, I came across these quotes from the head of the hospital’s board of directors:

“These characteristics tend to confirm the lowly status of the white man in the scale of human evolution, and to establish closer analogies with primitive anthropoids than exist between these and other races of mankind.”

“The degenerative tendencies of the white race revealed by statistics, are due, essentially, to the influence of unfavorable hygienic surroundings; to unfavorable social (including moral) environment; to all the causes which lead to a bad heredity, vice, dependency, and degradation, and which are acting simultaneously upon this ethnologically inferior and passive race which is struggling for existence with our superior and dominant population.”

What if their chair of anesthesia had authored a paper with the following passage:

“Confining ourselves to the salient peculiarities of surgical interest, we shall insist, with all observers, on the lessened sensibility of the white nervous system to pain and shock. It is also believed—and my personal experience confirms this impression—that the tactile sensibility as revealed by the aesthesiometer is lessened. This would appear to be associated with a histological difference in the development and shape of the tactile papillae of the skin. This diminished peripheral sensibility is in harmony with the inferior organization of the white race. Diminished sensibility is not peculiar to whites, but common to all primitive races. Livingston was one of the first to call attention to the fact that white people can undergo the most painful operations with apparent indifference. This combination of circumstances—i.e. a naturally diminished peripheral sensibility, coupled with a more passive condition of the mind—makes the white man a most favorable subject for all kinds of surgical treatment with or without preliminary anesthesia.”

What should I think? Maybe there’s some flexibility in the base pay? Of course, I would not join a place where the figureheads view me as inferior. Yet these quotes are not from some mythical figures in Ghana, but have been taken almost directly—except for reversing the races— from the writings of Rudolph Matas, whose face adorns the seal of the the Southern Association for Vascular Surgery (SAVS).

This, however, is about to change. In his 2023 SAVS Presidential Address, William D. Jordan, MD, acknowledged a concern “that our image among many young surgeons is negatively impacted by having his likeness on our seal. Many of us have great respect for the work he has done, but some have expressed concerns about parts of his academic work that was offensive and not respectful to disadvantaged groups of the day.” President Jordan then called on members of the society to help design a new seal and “turn our eyes to the future.”

This clash between past and present is certainly not unique to our field. Perhaps the most public and possibly illuminating debate came over the presence of Confederate monuments in the United States. Defenders of the statues often cite their role in preserving history. A look at the actual timeline of their construction points to a more dubious purpose.

The American Civil War exacted a disastrous toll on the population of the South. Approximately 20% of Southern White men of military age were killed. Almost every family lost at least one member. In the decades after the war, numerous memorials were built to remember the dead. These were placed in solemn areas for contemplation, such as cemeteries. Starting around 1890 and peaking in the early 1900s, a new type of monument began to appear. Giant stone statues of Confederate leaders like Generals Robert E. Lee and Thomas “Stonewall” Jackson were erected. Now, instead of places for reflection, the monuments were positioned in public areas, such as town squares, courthouses, and state capitols. Rather than mourning the dead, the purpose of the new statues was clearly a validation of Confederate values during the Jim Crow segregation era. They seemed unequivocally designed and located to intimidate and discourage Black Americans from asserting their rights. Need more evidence? Ask Senator John Sharp Williams from Mississippi. At a 1927 dedication ceremony for a statue of Jefferson Davis, Senator Williams proclaimed that “[t]he cause of White Racial Supremacy, which . . . is not a ‘Lost Cause.’ It is a Cause Triumphant. . . The white man’s family, life, his code of social ethics, his racial integrity—in a word his civilization—the destruction of which in the slave states was dreaded . . . are safe.” See? These racists wanted to make it so clear that the Confederate statues represented White Supremacy that they just straight up handed out receipts.

Decades later, a new surge of Confederate imagery appeared as a backlash to the Civil Rights Movement. Georgia redesigned its state flag to include the Confederate symbol in 1956, and in 1961, South Carolina began to fly the rebel battle flag at its capitol building, where it would remain until 2015. Also undermining the claim that these monuments were constructed to preserve the local history of the South is that they were erected in 31 states. The Confederacy only consisted of eleven.

It is important to recognize and celebrate the achievements of historical figures. Still, we must maintain a critical perspective and acknowledge the full context of their lives and actions. We should strive to learn from the past while recognizing the limitations and biases inherent in our understanding. We can admire Thomas Jefferson’s accomplishments without ignoring his status as a slave owner. The latter should be scrutinized and studied as an example of the dangerous potential of the duality of man. Location and context are critical. Immortalizing individuals with giant marble statues seems more the domain of authoritarian regimes than advanced democracies.

Malachi Sheahan III

Some argue that judging historical figures through the standards of today is unfair and term it presentism. There is ample evidence that as we become more easily connected to others through technology, continued on page 4

FROM THE COVER: BASIL-2 POINTS TOWARDS ENDOVASCULAR-FIRST REVASCULARIZATION STRATEGY IN CLTI PATIENTS

bypass patients and 45% of best endovascular therapy patients,” Bradbury continued. “There is no significant difference of 30-day mortality but you can see that the median survival of the two groups is quite different.”

CLTI is the “severest manifestation” of peripheral arterial disease (PAD) and presents as ischemic pain at rest or tissue loss, or both, the authors detail in The Lancet Against this backdrop, Bradbury and colleagues were comparing effectiveness of a vein bypass-first with a best endovascular treatment-first revascularization strategy in terms of preventing major amputation and death in patients with CLTI.

“It is important to emphasize that the best way of analyzing this trial, which is the way our statistical colleagues have done it, is on the intention-to-treat population; however, for completeness they have done some sensitivity analyses, and this includes a per-protocol analysis, which includes only patients who were adherent—that is, they received the allocated intervention they were randomized to,” Bradbury explained at CX. “They also performed an as-treated analysis, which is based upon the first revascularization that the patient actually received following randomization, and as you can see here they both trend towards reduced amputation-free survival in the vein bypass-first group.”

The BASIL-2 co-investigators, namely statistician Catherine Moakes, MSc, senior nurse Gareth Bate, PGDip, and academic lecturer Matthew Popplewell, MD, all of Birmingham, and Lewis Meecham, FRCS, from the University Hospital of Wales in Cardiff, Wales, also presented during the session on the journey from BASIL-1 to BASIL-2, a hypothesis-generating prospective cohort study, methodology, study limitations and future work, among other topics.

BASIL-2 was an open-label, pragmatic, multicenter, phase 3, randomized trial performed at 41 vascular surgery units in three countries: the United Kingdom (n=39), Sweden (n=1) and Denmark (n=1). The central site was the University of Birmingham. “Eligible patients were those who presented to hospital-based vascular surgery units with [CLTI] due to atherosclerotic disease and who required an infrapopliteal, with or without an additional more proximal infrainguinal, revascularization procedure to restore limb perfusion,” they state in The Lancet

Bradbury and colleagues randomly assigned participants 1:1 to receive either vein bypass or best endovascular treatment as their first revascularization procedure through a secure online randomization system. The Lancet paper details that participants were excluded if they had ischemic pain or tissue loss considered not to be primarily due to atherosclerotic PAD. Most vein bypasses used the great saphenous vein and originated from the common or superficial femoral arteries, the authors communicate, while most endovascular interventions comprised plain balloon angioplasty with selective use of plain or drug-eluting stents.

Patients were followed up for a minimum of two years, Bradbury et al write, with data collected locally at participating centers. In England, Wales and Sweden, the authors note, centralized databases were used to collect information on amputations and deaths. Data were analyzed centrally at the Birmingham Clinical Trials Unit.

The primary outcome of amputation-free survival was defined as time to first major (above-the-ankle) amputation or death from any cause measured in the intention-to-treat population. Safety was assessed by monitoring serious adverse events up to 30 days after first revascularization.

Between 22 July, 2014, and 30 November, 2020, the triallists enrolled and randomized 345 patients with CLTI—65 (19%) women and 280 (81%) men with a median age of 72.5 years (62.7–79.3). The patients were randomly assigned to either the vein bypass group (172 [50%]) or the best endovascular treatment group (173 [50%]).

Bradbury detailed at CX that major amputation or death occurred in 108 (63%) of 172 patients in the vein bypass group and 92 (53%) of 173 patients in the best endovascular treatment group. The relevant mortality numbers were 91 (63%) among the vein bypass group and 77 (53%) in the endovascular arm.

In both groups, the authors write, the most common causes of morbidity and death— including that occurring within 30 days of their first revascularization—were cardiovascular (61 deaths in the vein bypass group and 49 in the best endovascular treatment group) and respiratory events (25 deaths in the vein bypass group and 23 in the best endovascular treatment group). They add that the number of cardiovascular and respiratory deaths were not mutually exclusive.

In the discussion section of their paper, Bradbury et al consider how their findings compare to those from the BEST-CLI trial, which were presented for the first time last November. “At first glance,” they remark, “our results appear to conflict with the BEST-CLI trial.” However, they note that there were “many differences” between the two trials, including the primary endpoint. “Our clinical experience suggests that few patients with [CLTI] are deemed suitable and have an optimal vein for infrapopliteal bypass,” Bradbury and colleagues comment, adding