Sabine Steiner and Fabrizio Fanelli dive into a hot debate that's been rocking the boat in United States and making waves in the world of endovascular medicine this summer: the overuse of endovascular procedures. Find out their views!

Can we strike the right balance in peripheral endovascular interventions?

When I was asked by the editors of the PVI homepage to comment on the recent debate about the overuse of endovascular procedures and, in particular, atherectomy devices [1], I found it difficult to do so without knowing the clinical details and navigating the US healthcare system with its complex interplay of health economic, legal, and regulatory policies. However, as an interventionist and clinical researcher in the field of endovascular interventions, I am well aware of the difficult treatment decisions we must make on a daily basis in the light of limited clinical trial data. While current guidelines list several criteria for performing revascularization and performance goals to be achieved, clinical practice often requires a more complex decision-making process taking into account the patient’s individualized risk and symptom burden, application of the available (often sparse) evidence to the specific patient and subsequent shared decision making with the patient’s wishes as well as economic considerations. The spectrum of patients I treat has become increasingly complex over the past decade due to the aging of the population and the increase in co-morbidities including diabetes and chronic kidney disease. In fact, we are often confronted with the situation where patients with advanced disease, who are at highest risk of intervention (and who potentially benefit the most), are referred to our center relatively late, after several inadequate treatment attempts, indicating a risk-treatment paradox also in the care of PAD patients.

A recent multi-society statement clearly outlined key issues in the complex care of patients with PAD, including highlighting the benefits of multidisciplinary teams to improve patient outcomes[2].

Similarly, we need collaborative research efforts to advance the field of endovascular interventions. While randomized controlled trials are the gold standard to address areas of clinical equipoise and several important studies trials have been published in the last few years, observational research seems essential as not all clinical decisions can be based on outcome data from RCTs. Here we have another opportunity to increase the credibility of observational research through multi-institutional collaboration. Given the rapid development of new imaging technologies, the use of artificial intelligence, and the potential of multi-omics for in-depth characterization of pathophysiological processes, we need to bring specialists from different research fields on board to make these advances accessible to vascular research.

All these aspects just underline how necessary intensive collaboration and exchange are in the field of vascular medicine that has been advocated over so many years and I highly appreciate working with many outstanding physicians and researchers from different fields to improve outcomes for this often-neglected patient group

Sabine Steiner, MD

References:

1.    PAD Procedure Overuse: A Field in Peril or 'A Few Bad Apples'?
2.    Multi-Society Message on Peripheral Artery Disease: A Significant Public Health Issue that Remains Underrecognized, Undertreated, and Underserved