Good

Morning. I want to thank the Ibero American Society of Interven:onism (SIDI) for having appointed me to represent them today, on the ques:on of who performs vascular procedures in La:n America, and the Society of Interven:onal Radiology (SIR) for the interest and :me alloFed to this symposium.

So, who performs vascular procedures in La:n America?, or, in all of America, or, since I am speaking on behalf of the Ibero American Society of Interven:onism, what is the situa:on in those countries? This is clearly a global issue, that can be of interest in even larger areas. As any one who has been involved in academics knows, in order to gain :me to answer a dicult ques:on, it is common to begin with a remark such as

That is actually a good ques:on! Apart from gaining a few seconds to organize your thoughts, what is really meant in this case

is that this is not an easy ques:on to approach. Who knows? means where to ask, also known as a search strategy. The sources include colleagues from other hospitals, some:mes our own compe:tors, also hospitals and interven:onal radiology services, scien:c socie:es, the companies that are selling their products to those who actually perform the procedures, or plain old literature searches.

Even if the answer is straighQorward, it is important to explore it in depth.

Many colleagues have a limited view of what happens in nearby hospitals. Each prac:ce can have its own rules and turf baFles that can be handled in various manners, so many colleagues have a limited view of this issue on their own ci:es, let alone their countries, or the con:nent they live in. Some may even throw numbers based more on wishful thinking than on evidence. If the colleagues you ask are not from your same specialty, as is my case if, as a radiologist, I interrogate cardiologists or surgeons, those compe:tors may not be willing to answer and may even become suspicious of your inten:ons when you ask around. The answer to our ques:on may not be found this way.

Hospitals and IR services suer from the same dicul:es in answering this ques:on, due to the very dierent scenarios that can be found, depending on the strength of each service, the history of each ins:tu:on or on the policies of each hospital or service.

Some scien:c socie:es may possess this kind of informa:on, but they can present a picture that is distorted (such as the terracoFa Statue of Liberty shown, which sits on Buenos Aires, not on New York) due to the standpoint from which surveys, if available, are performed. If there is informa:on at all about this issue, it may suer from registra:on problems that make this informa:on unreliable. Even with under- or over- registra:on and a wide range of physician response to surveys, scien:c socie:es may be the ones in a beFer posi:on to solve this issue.

I actually asked some company representa:ves in Colombia to try to nd out who they were selling their vascular devices to. Even though some were willing to share this kind of informa:on, some industrial conden:ality issues aroused. Most informa:on is about marke:ng interests, and some sales informa:on simply cannot be shared on the basis of suspicion of industrial espionage. The boFom line is that they probably dont care, as long as they sell

Literature on this maFer emphasizes all the known issues, such as turf baFles, or trends. There are several editorial posi:ons, very dierent standpoints, but scarce or unpublished sta:s:cs on who actually performs vascular procedures in La:n America.

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This is an old problem. To understand the vascular wars, we must know whats at stake, where are the baFleelds, and whos gh:ng

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The issues are well known. Some are related to the history of each specialty involved in vascular diseases, some center on Turf BaFles. Posi:ons and ar:cles about the importance of skills abound, including the technical skills related to the procedures themselves or those related to imaging and radia:on protec:on issues, and those clinical skills necessary to deal with pa:ents. Reimbursement, of course, is a crucial issue, especially if there are inequali:es across dierent specialists.

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The baFleelds may help decide who is involved. Vascular territories that need a surgical approach, imply that a surgeon has to be in the team or be the main operator. Similar situa:ons may apply for other vessels.

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Whos gh:ng? Interven:onal radiologists, Interven:onal Cardiologists, Vascular Surgeons, Neurosurgeons, Neurologists, Radiologists that do not perform vascular interven:onal procedures on a daily basis but that can be exposed to these cases when on call. The rst three are the usual suspects.

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Dietrich described these three main players, with the caveat that one- liners may not be fair enough to describe them. According to him, for vascular surgeons, Peripheral vascular disease has always been our domain because we are the only ones capable of total care, from diagnosis through procedure and follow-up.

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For radiologists, Endovascular procedures are historically our territory. Surgeons are ill- trained for percutaneous approaches and cardiologists have no experience in the treatment of peripheral vascular disease.

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For cardiologists, An artery is an artery, a balloon is a balloon and it does not maFer in which artery you are placing the stent. We have the pa:ents, the laboratories and the catheter skills.

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Based on the search strategy I have outlined, this is an approximate view of what happens in Colombia. Most vascular procedures are performed by cardiologists, radiologists have a good share, but mostly on visceral non-renal cases, some peripheral cases, neurovascular cases and venous accesses. Surgeons are involved mostly on aor:c procedures, and other specialists include neurosurgeons performing caro:d sten:ng.

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In many of our countries, there appears to be a similar distribu:on, where cardiology prevails, in varied propor:on, with radiologists in second place. In some cases, this has to do with historical issues, or with the availability of cardiologists to pa:ents with coronary and extra coronary involvement, and with their availability of the necessary equipment and hospital infrastructure.

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Surgery prevails mostly in hospitals where vascular procedures are performed by more than one group, especially taking into account aor:c procedures, which usually require surgical techniques for the inser:on of wide-bore devices. With no hard evidence to support this, there are some countries where this kind of situa:on extends to areas where no specic surgical skills are needed, such as peripheral or visceral endovascular treatments.

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Radiology prevails mostly in my wishful thinking, or in countries where surgeons are not well trained in this procedures, or where radiologists came rst. Again, with no surveys or studies to conrm this, in most cases vascular procedures are performed by whoever is willing to do them, with a varied amount of exper:se, and depending on the availability of the devices needed. Each group has arguments in favor of their own involvement and against other groups par:cipa:on. Those arguments can be academic, philosophic, pseudoclinical or, mostly, nancial.

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I believe there are three points in which we can all agree: it doesnt look good, more research is needed, and teamwork may be the way to go.

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No maFer which player you ask, it seems it can always be beFer

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We really need to address this issue with evidence. Surveys and sta:s:cs and informa:on from the scien:c socie:es is needed to understand the real picture and to try to determine what policies, if any, are needed to promote less invasive treatments.

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If all the main players are involved, the interven:onal playground should evolve into a real and prac:cal alterna:ve for vascular diseases in a global manner.

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Thank you for your aFen:on

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References Baerlocher MO, Asch MR, Hayeems E: Current issues of interven:onal radiology in Canada: A na:onal survey by the Canadian Interven:onal Radiology Associa:on. Can Assoc Radiol J 2005; 56(3): 129-139. Domnguez Asenjo R: La disyun:va del cirujano vascular frente a la radiologa intervencional. [The vascular surgeon doubt in front of interven:onal radiology]. Rev chil chir 2002; 54(4):319-321. Domnguez R: Quo vadis ciruga arterial: convencional o radiolgica intervencional? [Quo vadis arterial surgery: conven:onal or interven:onal radiology?] Rev Med Chil 1996; 124(11):1381-1384. Grava-Gubins I: Eects of various methodologic strategies. Survey response rates among Canadian physicians and physicians-in-training. Can Fam Physician 2008; 54(10): 1424-1430. Kimura Fujikami Y: El radilogo como interconsultante. [The radiologist as a consultant]. Rev mex radiol 1999; 53 (3): 91-92. Lakhan SE, Kaplan A, Laird C, Leiter Y: The interven:onalism in medicine: interven:onal radiology, cardiology, and neuroradiology. Interna:onal Archives of Medicine 2009; 2:27. Levin DC, Flanders SJ, SpeFell CM, Bonn J, Steiner RM: Par:cipa:on by radiologists and other specialists in percutaneous vascular and nonvascular interven:ons: Findings from a seven-state database. Radiology 1995; 196: 51-54. Levin DC, Rao VM, Bonn J: Turf wars in radiology: the baFle for peripheral vascular interven:ons. J Am Coll Radiol 2005; 2:68-71. Levin DC, Rao VM, Bree RL, Neiman HL: Turf baFles in radiology: how individual radiologists can respond to the challenge. Radiology 1998; 209: 330-334. Marunez-Rodrigo JJ: Competencias profesionales: del conicto a la oportunidad. [Professional competencies: From conict to opportunity]. Radiologa 2008; 50(1): 5-10. Palmero da Cruz J: Quo vadis, intervencionista? [Quo vadis, interven:onalist?] Intervencionismo (SIDI-SOBRICE) 2009; 9(2): 50-51. Taylor RA, Qureshi AI: 10 most commonly asked ques:ons about training in interven:onal neurology. The Neurologist 2009; 15(4): 230-233. Veith FJ, Marin ML: Endovascular technology and its impact on the rela:onships between vascular surgeons, interven:onal radiologists, and other specialists. World J Surg 1996; 20: 687-691. Zarins CK: The vascular war of 1988. JAMA, 1989; 261(3): 416-417.

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