Great Debates in Vascular Medicine

This session was perfect for the SCAI conference. Two opposing investigators were pitted against each other to debate 2 distinctly different treatment modalities. At the end of the debate, the physicians in the audience voted in live time in favor of 1 of the 2 treatments.

The first debate entitled, “Management of Deep Vein Thrombosis: Intervention is Now Mainstream” focused on the question of whether optimal medical therapy (OMT) only or in combination with interventional cardiology is the preferred treatment for deep vein thrombosis (DVT). In favor of interventional medicine for removal of large plaque burdens, Chris Metzger, MD, of the Wellmont CVA Heart Institute based in Kingsport, Tennessee, argued that the clinical data supports early intervention by catheterization. He pointed to a meta-analysis that showed a randomized controlled trial (RCT) where the larger the thrombus left un-removed, the greater the incidence for later disease events. In general his argument was that he was aware that this approach does not directly address other collateral vasculature problems, but it may help these areas through improved circulation, as well. On the other side of the argument, Raghu Kolluri, MD, of the Prairie Heart Institute in Springfield, Illinois, presented the case that the current clinical data and his own personal experience has been that we really do not know enough about DVT to automatically assume that intervention is going to be the best approach. Ultimately, 62% of the physicians attending this SCAI meeting favored intervention as described by Dr Metzger.

The next subject entitled, “Stent is Superior to Atherectomy for Complex Superficial Artery Disease” addressed whether the veteran stent technologies promote superior outcome as compared to the lesser used plaque removal atherectomy approach. J. Dawn Abbott, MD, an interventional cardiologist at Rhode Island Hospital started by presenting data in support of using stents and pointing out that there is little to zero clinical data available for analyzing atherectomy for treating complex superficial artery disease. For stents, however, it has been established that they can work superior to balloon angioplasty. All patients should simultaneously be on optimal medical treatment (OMT). By contrast Lawrence A. Garcia, MD, Chief of Interventional Cardiology at St. Elizabeth’s Medical Center in Boston, Massachusetts, argues that stents are not the default therapy in all cases. He makes the point that just because most of the clinical data available does indicate that stents can help, this does not mean that they are superior to atherectomy. Dr Garcia points out that stent failures 10 cm plaques can lead to 15 cm plaques forming which can lead to 20 cm plaques. In the end the audience was virtually undecided, with 52% favoring stenting, while 48% favored atherectomy.

Another debate between Bruce H. Gray, DO, of the Greenville Hospital System in Greenville, South Carolina, and Robert D. Safian, MD, of Beaumont Hospital in Royal Oak, Michigan, addressed whether intervention was always preferable for treating renal arteriostenosis. Dr Gray argued against treatment, while Dr Safian argued in favor of it. Dr Gray argued against on the basis of poor quality clinical data. He also pointed to the lack of benefits seen with respect to hypertension. Dr Safian argued strongly that the most important measure from the clinical trials involves measures of kidney function such as creatine levels and glomerular filtration rates. Also, he pointed out that clinical trials to date have excluded the patients that are most likely to benefit from intervention. In the end, 77% of polled physicians agreed with Dr Safian that intervention is favorable for treating renal arteriostenosis.

The final debate entitled, “What We Need is a Trial of Best Revascularization Versus Best Medical Therapy in Asymptomatic Carotid Artery Disease.” This was the most animated of the debates, with Dr Alex Abbou-Chebl, MD, an interventional neurologist at the University of Louisville in Louisville, Kentucky, leading off by stating that there should be clinical trial for this because OMT on its own does not prevent strokes completely, long-term drug compliance is not as reliable as an interventional technique, and no such RCT has been completed for carotid artery disease. Most importantly, if going forwards with clinical trials, Dr Abbou-Chebl stresses that other indicators besides just percentage restenosis such as plaque morphology need to also be considered with respect to whether or not to perform interventions. On the other side, Mehdi Shishnehbor, DO, of the Cleveland Clinic in Ohio, strongly argued against the need for further clinical trials. He stated that stroke prevention benefits are dependent on three patient specific parameters: life expectancy, peri-procedural death risk, and actual risk if only OMT is pursued. In the discussion Dr Metzger pointed out and most agreed that you should not treat if you are dealing with 50% or less occlusion. Ultimately, Dr Shishnehbor won the debate, having received 68% of the votes from the physicians.

The atmosphere was impassioned and respectful at all times, with the participants consistently opposed right until the end. Consensus opinion was most significantly in favor of performing interventional treatment for renal arteriostenosis.