A Look at Vascular Intervention and the VEITHsymposium

Author(s): 

Cath Lab Digest talks with Frank J. Veith, MD, Professor of Surgery, The Cleveland Clinic Lerner College of Medicine and New York University; The William J. von Liebig Chair in Vascular Surgery, New York University Medical Center; Cleveland, Ohio and New York, New York.

The VEITHsymposium is now in its 45th year 

(www.veithsymposium.org).

What is covered in the VEITHsymposium?

Our symposium is designed to cover the state-of-the-art in non-cardiac vascular treatment, including natural history. The symposium addresses both interventional and non-interventional or medical treatment. As such, our meeting should appeal — not as it has in the past, mostly to vascular surgeons — but to all vascular specialists who are interested in treating non-cardiac vascular disease. A vascular patient is a multi-vascular bed patient. In other words, if a patient has carotid disease, they are much more likely to have a myocardial infarction or some other vascular problem, and vice versa: if a patient has peripheral vascular disease and critical limb ischemia, then they are more likely to have coronary disease and carotid disease. 

Many vascular surgeons are acquiring catheter and wire skills.

In 1996, when I gave the presidential address to the Society of Vascular Surgeons (SVS) on Charles Darwin and vascular surgery, I made the point that vascular surgeons had to become endo-competent if they were to survive. At that time, there was a lot of pushback and resistance. People didn’t pay much attention. Fortunately, after a short period of delay, at least most of the younger vascular surgeons and younger leaders in vascular surgery embraced that concept. But it took a little while. 

Can talk about the multidisciplinary nature of the VEITHsymposium?

Much of our faculty are “non-surgical” vascular specialists. That is, those in vascular medicine, interventional cardiology, and interventional radiology. I say “non-surgical” in quotes, because if you look up the word surgery in the dictionary, it is defined as the treatment of diseases and injuries “by manipulative means”. It says nothing about cutting, sewing, or open exposure of vessels. Fundamentally, all manipulative treatment is surgical.

What is the international guest faculty (IGF) program at the VEITHsymposium?

The IGF program is a new, experimental program to see if we can obtain industry support indirectly for sending younger and less well-known individuals in order to help them financially so they can attend the meeting. Industry cannot directly give money to fund the travel and hotel expenses for vascular surgeons and vascular specialists to go to meetings. The international guest faculty program is an idea we had that would allow industry to support in general, not specifically, the travel and meeting expenses for individuals so they can come to our meeting. We are also putting our own money into the fund, enough to fund the travel expenses for 20 international guest faculty members, but we hope that industry pitches in and makes donations that will support many other international guest faculty members’ expenses. 

We also still have the associate faculty program, which is a program whereby younger trainees and less well-known vascular specialists can submit abstracts that are presented. Their abstracts get published, this year in the Journal of Vascular Surgery, and we give them a reduction on the registration fee. They get the opportunity to present their work, some of which is really quite outstanding, at our meeting, and the abstracts are citable as literature citations. 

VEITHsymposium has always had a strong international component.

About 40% of our attendees and at least that number of faculty come from outside the United States. That international presence enriches our meeting, because many of the new developments come from areas outside the United States. Not only are other parts of the world producing leading concepts and initiatives, but they have a greater access to new and innovative devices, because of some of the restrictions that are imposed in the U.S. by our FDA. Restrictions in other parts of the world are less stringent, and accordingly, some of the clinical work with new devices comes from other parts of the world. We want the individuals doing that innovative work to make it known to all of our attendees. The techniques that are going to work will ultimately be approved by the FDA and could even occur sooner because of the fact that we are familiarizing attendees with outside-U.S. innovative work.

Attendees and non-attendees can purchase access online as well.

Yes. We record the entire meeting, including audio and slides from every talk, plus the panel discussions and other discussions that follow, so that it is possible for people who do not come to the meeting to buy it for a fairly reasonable cost and then study it at home or at work, outside the time of our meeting. We continue to do it, even though it is moderately expensive for us, because the large number of exciting developments and updates mandate concurrent sessions. Anyone who comes to our meeting can purchase it at a very nominal cost ($75). They can listen to talks they want to hear but couldn’t because they were perhaps at another talk, and the library is indexed to the program. It allows anybody who conscientiously wants to learn to continuously have access to our whole program after the meeting. If one has heard a talk that is particularly interesting and they want to hear it again to get details that they might have missed during the actual presentation or get references, they can go back and re-listen to it as many times as they want. For myself, I find it very useful. I will remember a certain talk, but I can’t remember all the details, and when I want to go back and review it, I find this is very simple to do.

What are some of the hot topics for this year’s meeting?

There are so many interesting new developments. Without necessarily putting them in order of importance, some of our hot topics include:

  • Exciting new developments and treatments for lower-extremity limb-threatening ischemia. We devote a lot of time to this every year. 
  • New medical treatments to delay or stop the progression or stop the complications of atherosclerosis. These treatments are tremendously exciting and every vascular specialist should be aware of them. I was reading today that that patients with lower-extremity ischemia routinely are not given lipid-controlling drugs, or if they are given the drugs, they are not given them optimally. That’s catastrophic, in my mind. Everybody wants to do procedures, but these patients can benefit enormously from good medical management with statins, PCSK9 inhibitors, and many other new options. They live longer, they live better, and have fewer adverse events in the procedure that one does on their limb. The medical treatment of patients with atherosclerosis is expanding and developing at a very rapid rate. Almost to the point that one can say many lesions won’t cause the adverse events that they did in the past. Obviously, there will always be patients with atherosclerosis and the consequences thereof. But the ability to better treat these patients with the new drugs and other treatments that are available is really striking. 
  • New developments in carotid disease and better techniques for performing carotid artery stenting. 
  • New and better treatments for dissecting aneurysms, an area that was very difficult to treat in the past, particularly Type B aortic dissections and complicated Type B aortic dissections. We are now seeing ways to improve the outcomes for such patients and analyzing some of the original thoracic endovascular aortic repair (TEVAR) treatments that we thought would dramatically improve treatment in that area. We are seeing that TEVAR doesn’t always work and that one has to do secondary procedures, and so forth. 
  • Venous disease. There are a lot of exciting things in this area. It is a whole new vista for invasive vascular treatments that benefit patients.
  • Imaging and guidance, both dramatically improved. 
  • Avoiding or minimizing radiation exposure. 
  • Better drug-eluting stents and balloons. 

It is a very exciting field to be in, because of the plethora of new things that make our treatments easier and better. 

Do you also cover renal denervation and some generalities? 

We do, under medical treatments. We also review all the older areas of interest, like thoracic outlet syndrome, spinal cord ischemia and how to prevent it when one is doing a thoracoabdominal aneurysm or thoracic aneurysm repair, either endo or open. We still include the value of open surgical techniques and how they fit into the spectrum of care for these vascular patients. We discuss how to treat complications better, looking at the newer methods for treating them in a more dependable way. We discuss the value of various trials. We deal with a lot of the issues important to vascular specialists and vascular surgeons. We even include some of the newer key elements in cardiac and valvular treatment as well, but that is just a smattering, to make sure that vascular surgeons and vascular specialists, who aren’t primarily interested in the heart, know what’s going on that might be relevant to them.

We have experts from all over the world — the opinion leaders and the key innovators — come to our meeting and speak, irrespective of their specialty. We think we are of greater value to the non-surgeon vascular specialist. What we are trying to do is integrate and encourage vascular medicine specialists and interventional cardiologists to make up part of our program, which is a more global vascular program. 

How has the meeting evolved over the years?

This is our 45th year. It has been incredible. The meeting started out with maybe 10 faculty and a hundred people, in a small hotel in midtown Manhattan. Of course, it was all open vascular surgery at that point. We have grown as the field has grown. For example, the first meeting didn’t involve anything about veins or arteriovenous (AV) malformations or AV access. Now our meeting involves all these peripheral areas. In addition, faculty is probably at 800 this year. The size of the meeting has grown as well. Today, we have about 5000 attendees. There are two things that were really seminal to our meeting. One was involving industry. We think industry is as important as the physicians and have them as partners. They come up with ideas, help to finance the meeting, and make all this new technology possible. The other seminal event for us was the short talk. The gist of what needs to come across to our audience and the world is what is new and exciting, and that can be done in 5 or 6 minutes without going into all the background. The short talks at VEITHsymposium are something I came up with after watching television. Henry Kissinger would be on a news show and they would give him just 2 or 3 minutes to talk. That idea of a short talk enabled us to expand our faculty to cover things that we would otherwise not be able to cover, and to allow opposing views and controversy to be better expressed. Not by a single person, but by multiple people who perhaps have diametrically opposing views. They both could talk and then our audience could make up their mind who they wanted to listen to or who made the best case. Our meeting was unique in enabling that. 

Any final thoughts?

Interventional cardiologists are outstanding vascular specialists and need to come to our meeting to hear things that they don’t normally hear at their own meetings. Many interventional cardiology meetings are totally oriented towards technique, methodology, and equipment, and the results thereof. They really don’t cover the waterfront the way we do, with non-interventional treatments and natural history, which again, I think make our meeting unique and of particular value to non-surgical vascular specialists. 

I myself do attend interventional cardiology meetings, but most surgeons don’t go to these other meetings. If you only go to your specialty meetings with your colleagues and teammates, you are in a silo. One of the reasons our meeting was successful is that early on, I went to other meetings and saw what was out there beyond vascular surgery, and was able to push it into what we were doing. When you are cloistered in your own specialty, you miss out on things which can be beneficial. VEITHsymposium is a way to have all specialists benefit from each other. We are all in silos and that is bad. Consider the whole thrust into the endovascular field, which was a no-no for surgeons back in the 1980’s – everyone said, “It’s never going to work! How can you use a balloon to treat an artery?! These guys don’t know what they are doing.” But I saw, by going to interventional radiology and cardiology meetings, that these techniques worked, and I said, as vascular surgeons, we’d better be aware of what is going on, and when possible, adopt, embrace, and use it, because it is better for our patients. Hopefully, our meeting can do the same for other siloed specialists. 

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