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Advances in Vascular Surgery at Sunnybrook

The Division of Cardiac and Vascular Surgery at Sunnybrook has recently recruited two young vascular surgeons to their program with advanced endovascular training.

Andrew Dueck, following his initial surgical training at the University of Toronto in general and vascular surgery, was recruited to Sunnybrook Health Sciences Centre in 2007 (http://www.surgicalspotlight.ca/Article.aspx?ver= Winter_2009&f=NewStaff). Following fellowship training in vascular surgery in Toronto, he traveled to Phoenix, Arizona to pursue advanced endovascular training under Dr. Ted Dietrich at the Arizona Heart Institute (AHI). AHI is a state-of-the-art facility designed to provide open vascular, endovascular, and cardiac procedures together in one location. There are four operating rooms each equipped with C-arms for imaging, carbon fiber tables and the full range of the latest devices and stents for cardiac and vascular interventions.

"The dramatic changes required to train one individual in such a broad range of skills would be disruptive to current university training programs, the hospital and the practice of vascular surgery and radiology, but those barriers were never encountered. Wayne Johnston, Tom Lindsay, Richard Reznick, Robin Richards and Robert Maggisano made this unusual training regimen possible. They just made it happen." Giuseppe Papia has also recently pursued the Endovascular Fellowship at the Cleveland Clinic. This is a high volume operative fellowship available only to fully trained vascular or cardiovascular surgeons. He was appointed to the group at Sunnybrook this year. "Working together is an amazing experience for us. We know that Drs Reznick and Lindsay are doing things that we don't even know which are facilitating our success."

At Sunnybrook, cardiologists, cardiac surgeons and vascular surgeons had always worked under the administrative umbrella of the Schulich Heart Program. The question of which rooms could be used for hybrid cardiac and vascular procedures was immediately answered thanks to Brian Gilbert, head of the Schulich Heart Program, and Eric Cohen, director of the cath lab. They were well aware of recent advances in the field of endovascular surgery and were early and enthusiastic supporters. "The cardiologists and cardiac surgeons helped us build a centre that is equipped even better than the one I worked in at the Arizona Heart Institute".

Andrew's colleague and office-mate Giuseppe Papia (http://www.surgicalspotlight.ca/Article.aspx? ver=Summer_2009&f=NewStaff ) worked in two dedicated endovascular suites for vascular intervention in Cleveland. Overall there are 11 surgeons performing hybrid procedures in five specially equipped rooms at the Cleveland Clinic. Joe performed over 300 endovascular procedures "from skull base to the toes with every possible device available that you can imagine." There he worked with Roy Greenberg, a pioneer and world expert in branched aortic endovascular aneurysm repair (EVAR) for thoracoabdominal aneurysms. At the Cleveland Clinic they performed three to five of these complex cases per week. "The team spirit and efficiency at both of these centres was outstanding. If the surgeon is seen as the lead paddler of the canoe there was never anyone behind dragging a paddle or an anchor -- the rest of the team provided an outboard motor. Turnover time was generally eleven minutes. The dress code in the Cleveland Clinic operating room simplified communication. Staff surgeons wear white, residents wear blue and industry representatives wear orange. Everyone on the team takes great pride in the clinic and patients feel the esprit de corps."

Endovascular procedures are not new. Joe and Andrew emphasize that their vascular radiology colleagues have been performing angioplasty since the 1980s, and endovascular stenting for abdominal aortic aneurysms has become the standard of practice throughout Canada.

They are now pushing the envelope in terms of more complex hybrid interventions such as endovascular-aortobifemoral procedures, and catheterization through patches over profundoplasties to facilitate the introduction of balloons and stents in both directions. For example this allows "aorto-bifemoral bypasses" to be performed with two small groin incisions. These multilevel interventions allow patients to go home quickly, often in one to two days. More importantly they are spared the long period of recovery at home associated with open procedures. "The novelty is not choosing one or the other, open or endo, but being able to combine the best of both endovascular and open surgery for each individual patient. As the specialty evolves, the surgeons must also evolve. Daryl Kucey and Robert Maggisano were the pioneers at Sunnybrook who broke the ground with the radiologists, raised money for the equipment and the cardiac surgeons and cardiologists at the Schulich Centre. Dr. Maggisano became a tireless fundraiser, sharing his vision with a broad range of potential donors. Major donors became infected with

Dr. Maggisano's contagious enthusiasm, bought into the vision early and offered financial support, which in turn encouraged additional donations. These efforts enabled the purchase of the initial equipment. Brian Gilbert and Eric Cohen provided key administrative support to developing additional infrastructure. The diaphragm and the heart lung machine are no longer defining boundaries between vascular and cardiac surgery. These two surgical specialties have been one division at Sunnybrook for the past four years, and collaborate to perform cases in a combined fashion. There is a strong relationship with the division of cardiology with Drs. Madan, Dick, Strauss, Cohen and Radhakrishnan all playing an active clinical and research role. Most recently, the cardiac surgeons, cardiologists and vascular surgeons have come together to form a team for the performance of transfemoral aortic valve surgery.
Endovascular Suite at Sunnybrook
Endovascular Suite at Sunnybrook

In addition to the multilevel collaboration amongst specialties in the operating room and endovascular suites, Joe's presence in the cardiovascular ICU also helped bond the services together. He has especially good rapport with surgeons in the ICU and when attending in the ICU has helped nonsurgical staff understand the unique culture and values that inform post-op surgical care. Everyday at the Heart and Vascular Institute at Cleveland Clinic Foundation there are different trans-disciplinary rounds that build team cooperation. Tuesdays -- vascular medicine and surgery, Wednesdays -- aortic rounds with the cardiologists and cardiac surgeons, Thursdays -- carotid rounds with all disciplines including neurosurgery. "These provided an incredible educational forum where different disciplines treating the same disease discussed cases and approaches together. The spirit was that the patients belonged to the Clinic, not individual physicians, therefore everyone worked together to ensure they received the best treatment possible."

The Trauma service is another important area of synergy at Sunnybrook. "The trauma surgeons are excellent at vascular repair. They call the vascular surgeons only for replacement, bypass or reconstruction of unsalvageable, unrepairable vessels. It helps that we are friends who trained together and that they are so good at what they do."

The research agenda is a collaborative one. Andrew is working with Graham Wright and his imaging sciences group, a well-funded and productive research team developing measurement tools to replace older standards familiar to many surgeons such as the anklebrachial index. These measurements will introduce techniques that will allow assessment of microvascular disease essential to determine and predict the fate of more proximal interventions, and potentially a mechanism to evaluate stem cell therapies. Other important collaborative research includes the quest for developing non-contrast imaging for renal patients, a 3-dimensional model of the vascular tree using intravascular ultrasound that looks forward rather than only at cross-sectional images, and translational research to be sure that the advances in understanding and treatment are brought to the population throughout the province.

Joe's research is focused on his background in intensive care and his interest in patient safety and minimizing harm to patients through the standardization of process. With the support Rob Fowler and the Department of Critical Care Medicine, and Robin Richards, Joe has recently completed training at the Institute for Healthcare Improvement in Boston with Dr. Don Berwick and his team. "Don Berwick is probably the most respected physician in America and an absolutely inspirational speaker when it comes to patient safety. Escape Fire: Lessons for the Future of Healthcare is a must read for anyone who takes care of patients." His focus is on standardizing process for "handovers"-- the critical points in the care cycle where everything can potentially go wrong for patients. He is working on a formal process for handing over patients from the Operating Room to the ICU. He works in the Patient Safety Scholar program with Ed Etchells and Kaveh Shojania. Joe is also currently piloting and working on the implementation of the WHO Surgical Safety Checklist at Sunnybrook's two sites, and is working with the provincial SSCL working group. He is collaborating with Sherry Espin, Associate Professor of Nursing at Ryerson University, on evaluating the implementation process of the WHO checklist across the province as well as it's effect on operating room culture.


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