COMMENT& ANALYSIS NAVIGATING THE TECHNOLOGY LANDSCAPE AS A VASCULAR TRAINEE

I VIVIDLY RECALL SITTING IN THE back of the conference room as a medical student and marveling at the various approaches that could be used to solve vascular problems during the weekly “indications conference.” Every Monday morning, the creativity displayed at this conference to solve difficult problems served as a major draw for me into the field of vascular surgery, even though, to be honest, some of it went over my head at the time. During these hours, the senior residents and fellows seemed to have all the answers, and the attendings had no shortage of tips and tricks up their sleeves!

Fast forward a few years, and now self-expanding stents, balloons (drug-coated and plain), steerable sheaths, atherectomy devices, intraluminal lithotripsy, Fiber Optic RealShape (FORS) technology, laser fenestration, percutaneous fistula creation devices, transcarotid stent placement with flow reversal are but a few of the technologies that are commercially available to change the landscape of options that we offer our patients. I find it truly amazing that most of these were not in routine use when I was a medical student just a few short years ago! Recently, the PROMISE II trial was published in the New

England Journal of Medicine highlighting the advantages of venous transcatheter arterialization technology for end stage chronic limb threatening ischemia. This, I suspect, will likely spawn a new industry around this technology. It’s exciting to be a trainee in these times of technological advancement!

However, with these options comes a paradox of choice. Walk through the vendor displays at any vascular meeting and it can sometimes be paralyzing the number of device options available. This is especially important because not all of our training have the same access to these devices. So the question becomes: How should we bridge these knowledge and practice gaps? Even better yet, how should we think about each of these technologies as we go through training?

I’m no expert but I have been thinking of this lately, remaining fully aware that I am a product of my training institution, and that I won’t be exposed to everything out there. In talking with my attendings and peers, I’ve distilled a method to approach this problem:

Read and case plan with attendings

Taking an active role in case planning is essential. I try to come up with my plan for

Government Grand Rounds

treating a patient’s pathology (as if I were the attending) before I read the attendings’ plan in their notes and then discuss their approach with them. Clinic can be critical for this knowledge exchange. I’ve discovered that the operating room is not the place to come up with your initial plan.

Utilize the other human resources

In addition to planning with attendings, read and be familiar with the instructions for use (IFU) of the devices that you encounter. Pick the brains of the radiology technologists/ nurses, and device representatives—many of whom rotate through other hospitals and are chock-full of tips and tricks to get out of trouble. I find the device representative who gives an honest appraisal of the strengths and weaknesses of their product most valuable.

Deliberate exposure

It’s impossible to use every device during training—even in the most “early-adopter” health systems. I’ve found that most device reps are ready to do a quick in-service with resident/fellow teams to show how their device works and how it adds to the vascular surgeon’s toolbox.

It’s important during these sessions to also speak to the device’s limitations, and in what patient population in shouldn’t be used in. On this note, if you can, go to conferences and learn.

Keep an open mind

I’m not an “early adopter” but philosophically, it’s important to keep an open and inquisitive mind. My ultimate goal is to be able to select the best device that helps the patient in front of me. At the end of the day as the surgeon, I assume the majority of the responsibility for the operation and its outcome. Therefore, in my mind, these are tools to aid our patient and we should be exposed to as much as we can during training.

Journal—and work the back table

This next one, I heard at a conference from Dr. Venita Chandra of Stanford University: During the senior years of training, keep a log of devices you like—and why. It’ll serve you well as an attending, especially as you may be the pioneer of a new technology within the hospital system you take a job in. On that note, during training, spend some time working the back table as a senior learner. It is important to know how to prep the devices and troubleshoot malfunctions. It’s a given that over the next 10 years, technology for vascular disease will continue to advance. In the journey towards becoming competent, confident, and compassionate vascular surgeons we have to always think about the best option for the patient in front of us.