Dr. Frank J. Veith on the origins and future of limb salvage

Dr. Frank Veith is a man of many game-changing firsts. First to perform EVAR in the U.S. (with colleagues Drs. Parodi and Marin). First to conduct a large-scale, six-year, prospective multicenter randomized trial comparing autologous saphenous veins with expanded polytetrafluoroethylene grafts. In the words of Dr. Peter Gloviczki, Professor of Surgery of the Division of Vascular and Endovascular Surgery at Mayo Clinic, Veith has made “groundbreaking contributions to the endovascular revolution, to aortic stent-grafts, to the management of ruptured aortic aneurysms, to carotid artery disease, and to interventions for the treatment of vascular infections.”

For these reasons, members of the vascular community, experts and students alike, widely regard Veith as a living legend. And as the role of legend dictates, Veith wasn’t always admired for his willingness to break new ground. On the contrary, he often worked against a sea of resistance and stasis, sometimes stemming from what he might call “imperfect human nature.” This was especially pronounced in his extensive work in aggressive limb salvage. All of which makes the most recent accolade— a named Lectureship created by the Society of Vascular Surgery (SVS) in his honor — all the sweeter.

This past June, the SVS recognized Veith’s important contributions to peripheral artery disease (PAD) and limb salvage by creating the Frank J. Veith Lectureship. It is a striking distinction for the SVS to bestow upon someone as there are only two other named SVS Lectureships — the Roy Greenberg Distinguished Lecture created in 2013, and The Homans Lectureship established in 1950 at the SVS’s fourth annual meeting. Veith, who was SVS president in 1995 and one of the very few recipients of the SVS Lifetime achievement awards (2010), says he is “blown away” by the distinction, calling the lectureship a “singular honor” in his career.

The lecture, proposed by Veith’s colleague at VEITHsymposium, Dr. Enrico Ascher, and unanimously approved by the SVS council, will focus on limb salvage and ground-breaking research into the diagnosis and treatment of peripheral arterial disease (PAD). “Dr. Veith was the first to challenge many established dogmas that prevented successful attempts at limb salvage,” Dr. Enrico, Clinical Professor in the Department of Surgery at NYU Grossman School of Medicine, says. “Several of his pioneering and innovative surgical approaches to lower extremity arterial reconstructions, initially contested by many, are now established strategies in the armamentarium of the modern vascular surgeon.”

On the announcement of this high award, Vein Magazine had the opportunity to sit down with Dr. Veith to discuss several topics — chosen collaboratively by our advisors and contributors — ranging from limb salvage and CLI to a new book he authored and the secrets to his unique success (hint: he says there are no secrets, but don’t discount luck). Enjoy!

VM: Tell us about your role in the development of ‘limb salvage.”

FV: When I finished my training, my second job was at Montefiore Hospital, which was in the Bronx and was a largely indigent, poor hospital. And like all young vascular surgeons, I wanted to do aneurysm repairs, carotid endarterectomies, and the other major vascular procedures that comprised then what was largely vascular surgery. At that time, the standard procedure recommended for people with gangrene of their toes or foot was to amputate the leg below the knee and then fit them with a prosthesis. And it turns out, in the Bronx, for various reasons, we had patients with a high incidence of diabetes and bad arteriosclerosis, and we had very few patients who needed an aneurysm fixed or a carotid endarterectomy. But we had many patients that had threatened legs because of gangrene, ischemic ulcer, et cetera.

So in the late ‘60s and early ‘70s, because I didn’t have enough good vascular work to do in the standard procedures, the big operations, or operations on big arteries, and I had an abundance of patients with threatened limbs, we started cautiously to challenge the thinking of the day by doing reconstructive arterial procedures, largely bypasses. And much to my surprise and delight, many of the procedures worked. So we became more and more aggressive about trying to save the legs of these sick, old patients. And the more aggressive we got, again, we were surprised by some of the unknown procedures or not-widely-accepted procedures that worked for us.

There were many things wrong at Montefiore, but it had one very good thing. We had superb arteriography, and largely performed by our radiologist, Seymour Sprayregen. I stopped the vascular surgeons from doing arteriograms so that our radiologist could do them all, and he started doing them very well, and we got pictures of the arteries not only in the thigh and the upper leg, but we got pictures of all the arteries down to the toes. Most other people, in fact, no other people were getting arteriograms of that quality. And we were able to find vessels in the lower leg and foot that were patent, that weren’t obstructed, but was distal to obstructions. And these patent vessels, which we now could visualize, served as targets for very distal bypasses.

So we started doing these distal bypasses, first with veins and later with prosthetics. And remarkably and unexpectedly, they worked if they were done carefully. Sometimes they had to be redone when they failed, so we initiated and pioneered the idea of re-operating on these patients if an initial procedure failed. And we accumulated a large number of these patients and began to analyze them carefully and show what we were doing, when done by the system that we had developed, really worked. It wasn’t easy, and sometimes it was expensive because the patients had to stay in the hospital a long time to get their feet healed after they were revascularized, but it worked.

In the late ‘70s and early ‘80s, we presented this work at major national and international meetings, showing what we were doing was working, showing examples, and so forth. And we were routinely greeted with skepticism and sometimes actual hostility because people said we weren’t telling the truth. But we were.

So in the early years, we were regarded as somewhat mavericks and iconoclasts because we were challenging the thinking of the day and advocating against amputation, and we were somewhat a voice in the wilderness. But gradually, over the years, as the ‘80s progressed and as we presented this work, other people started to try it and found that they could also do it successfully and that it worked. That was the initiation of aggressive limb salvage, which was done by vascular surgeons with the collaboration of our interventional radiologists. And then, in the mid-‘80s and the later ‘80s, as percutaneous angioplasty was introduced in stents, we started to use them. Again,

going against traditional thinking because our patients were largely old and sick, and they couldn’t tolerate an aortofemoral bypass, which is a big abdominal operation, or retroperitoneal operation, but they could tolerate the placement of a balloon or a stent in their occluded iliac arteries.

So we started to do angioplasty at the outset before other vascular surgeons accepted it. And then frequently, because the disease was multilevel, we would have to do a bypass below an iliac artery or SFA that was treated with a stent or balloon. And again, multilevel disease, sometimes multilevel treatment, combining it with angioplasty and stents. And we presented this work in the early and mid- ‘80s, before all sorts of prestigious societies. And again, we were greeted with some skepticism, and sometimes more. But as time progressed, the idea of saving threatened limbs became accepted and a good part of vascular surgery.

And then, as time progressed into the late ‘80s and early ‘90s, other specialties beginning to treat occlusive vascular disease, namely interventional radiologists and interventional cardiologists, started to accept the idea that limbs should be saved. And now, in just last year or the year before, the American Heart Association came out with a very important position paper saying how amputation was a huge international problem. And we, as vascular physicians, should do everything possible to save limbs in these old, sick people. So even though we were first in the game, other specialties, such as interventional cardiologists and radiologists, consider it a very big deal and an important part of their practices as well.

The idea of amputation for ischemic disease is being addressed widely, not only in the United States, but everywhere, as a disease entity that deserves aggressive treatment. And many people have shown that it is very important to improve patients’ quality of life and allow them to ambulate and be cared for at home, even if they’re old and sick. So that is a little history of limb salvage and our role in it. We were really the first to advocate this very aggressive approach to saving limbs, even though many subsequent vascular surgeons and others have adopted or adapted the same ideas and, in some cases, expanded on them.

VM: You must be so proud to have initiated such important work with such an impact on patients.

FV: Well, I’m pleased that it was recognized. Because for many years, our contributions, even though they were published in very important journals and presented at very important meetings, were not accepted. Many other subsequent workers who adopted our ideas, for whatever reason, forgot to acknowledge us. So getting this lectureship is very gratifying for me. It’s recognition that we really were the ones who promoted this and, in the early years, promoted it against considerable resistance.

VM: It’s hard to be the first. How did you endure the criticism? Did it make your job less pleasant, or did you just have a thick skin?

FV: [Laughing] It actually stimulated us because we knew we were right. I mean, we had the patients. Some of my colleagues in vascular surgery, who we were very friendly with because we were part of their old gang, as it were, they were friendly with us socially and in every other regard. But they said, “Well, we just don’t believe you. You’re not telling the truth.” And they laughed at it, and we laughed with them. And then we’d say, “Well, come up and watch us.”

And people would come from Europe and other places. And then some of them, of course, would adopt our techniques. Others would say, “Well, we just don’t get x-rays like this. We can’t do it.” And it would be forgotten. But there were many others who did it and proved that it could be done successfully. And of course, all my trainees could do it because they were part of the process.

We published lots of papers. Hundreds of papers on various aspects of limb salvage.

VM: You started doing the basics when it came to limb salvage treatment, which is just remarkable, and then you started to introduce interventional approaches. Where do you see the interventional market going today as it relates to making strides or overreacting?

FV: People with threatened limbs from arteriosclerosis ischemia, often with diabetes, are sick, old people. If one can treat them with a less-invasive procedure and make it work, that’s better than doing a big, open operation. So, we’ve always been enthusiastic about angioplasty and stenting.

And now, with the new technologies that industry is developing (we and they, that is), other groups can treat very distal diseases, which is where most of these patients have their occlusive problems. So, we’re very enthusiastic about endovascular ways of treating ischemic limbs.

We’re not-so-enthusiastic about treating patients with relatively minor ischemia, who have, say, intermittent claudication. They’re easier to treat, but most of them don’t need treatment because they don’t walk very well.

They have heart trouble and various other limitations. So we think, to some extent, it may be that interventional treatments are being over-utilized for the minor degrees of ischemia, for whatever reason — because one can do it. But no procedure that one does in these arteriosclerotic vessels works forever. And all these treatment modalities, whether open or endo, are imperfect, and failure is part of the game.

So, the patients who need it the most are the hardest to treat. Some of the interventionalists that are doing this outside of vascular surgery are quite brilliant and doing great things, particularly in Europe and even in the United States. I think that some interventional treatment will prob- ably be the first line of treatment in 80% of patients with a threatened limb. But at some point in their treatment, they may need an open procedure as well. And probably some patients with threatened limbs are best treated with an open bypass as the first treatment. Not very many, but some.

So I think all that is being studied now, and hopefully, this lectureship will encourage further developments and progress in saving limbs. And I’m very pleased about that, and I’m particularly pleased that the SVS recognized this particular area as being an important one. Though vascular sur- geons did the pioneering work, it’s being largely undertaken by other interventional specialists. Probably quite justifiably because some of them are really good, and just do so-called peripheral work, that is non-cardiac work, interventionally. And clearly, the idea of having a center that is devoted to limb salvage, I think, is very important because you need multi-specialty skills to optimally treat these patients.

VM: VEITHsymposium brings together multi-specialty experts.

FV: There’s no question that the treatment today

for saving limbs is a multi-specialty effort. And yet, many amputations are being done in, for want of a better word, lesser hospitals that aren’t committed to this whole area of limb salvage because it’s not easy. As I say, the patients who need the treatment the most are often very difficult to treat, whether one’s treating them endo or open.

The easy cases, the ones with a single occlusion of the superficial femoral artery, probably, in most cases, don’t need to be treated. They’ll do just as well with conservative or medical treatment. And so a hospital or institution that has a center devoted to limb salvage, whether it’s led by an interventionalist or a surgeon, I think is going to provide the best care. It’s like anything else; specialization and even subspecialization make a huge difference.

And to do some of the distal bypasses that we perfect- ed, I think someone needs to have special training in that sort of care. Similarly, if one is going to do an interventional procedure on foot vessels or distal leg vessels, I think that is not something that every vascular specialist can do as well as every other one. There are stars in athletics, and there are similarly stars in treatment, and vascular treatment and the stars are the people that commit to it, devote themselves to it, and have a large experience.

VM: You have said limb salvage is not a glamorous area. Why should someone go into it?

FV: Because patients need it.

I mean the whole idea of an amputation for an old person (and we showed this in some of our early articles written by either my colleagues or me or a combination thereof ) that if a patient gets an amputation and they can’t be rehabilitated, in other words, they’re confined to a bed or wheelchair, or God forbid, they get two amputations and then they can’t do anything. It’s hard for them to turn over in bed. They die much more rapidly.

And you ask what the motivation is, why we all go into medicine, we go into medicine to try to make the lives of patients better. And that’s why we go into surgery, to try to save lives and improve quality of life, and the quality of life improvement is enormous for a patient who comes in with a smelly infected gangrenous foot and you save his foot and he walks out of the hospital. He puts on a tie in a shirt and goes back to work. I mean, that’s pretty gratifying.

The problem is it takes a tremendous amount of work. Failure is one of the modes that you have to deal with. And that’s why you need so much training because you’ve got to deal, not with a simple case, but with a very complicated case. And for that, you need a lot of experience and a lot of patients. And again, specialization is the answer. It’s not glamorous, and it’s very time-consuming and sometimes frustrating, but when it works, it’s very gratifying.

VM: What is an exciting new opportunity in limb salvage?

FV: One of the hottest new areas now, and we feature this extensively at VEITHsymposium, which will be in November, is the idea of arterializing veins. It has been around. Since the 1880s, people have been trying to reverse

the flow in veins. We tried it a lot. Enrico Ascher and I really tried. I forget where we got the idea, probably from the older literature where it had been tried, and failed. We tried to do it and disrupt the valves in the vein so that the flow would be redirected to the ischemic foot. We had some anecdotal successes, but we had lots of failures. And now, that is the hottest new technique in limb salvage, and interventionalists are doing it.

There’s a device called the LimFlow device that reverses the flow in the vein interventionally. There’s also a surgeon from Thailand, Dr. Mutirangura, who has been arterializing veins surgically, and there are other surgeons, Rich Neville, who has done it surgically in the United States, for instance. Roberto Ferraresi in Italy has studied the physiology of this. A number of vascular surgeons, as well as interventionalists, are doing it now. It works.

What happens is very dramatic because if you disrupt the veins and arterialize them by hooking them up to an artery, approximately, either with a bypass or endovascular technique, you save limbs that you otherwise couldn’t save. As I say, we tried it. It worked anecdotally in a couple of cases, and Enrico Ascher was leading that effort, and we published on it. We reviewed the history, and it didn’t work. We ultimately abandoned it.

But the fact is, it’s now working. It’s fascinating. So I mean, here is the chance to advance limb salvage way beyond what we even dreamed. And we were regarded as crazies, doing everything we could to save the limb. Now there are many new techniques that we couldn’t even use because we weren’t smart enough.

So, to me, if you ask why a young person should go into it, I think it’s an area of opportunity, and certainly, there’s a worldwide demand. It’s important to educate other physicians involved in the process, but what’s also important is to educate the physicians who aren’t involved in the process, so they know what can be done, so they can refer the patient to a center that is outstanding and caring for these patients.

VM: There are many barriers to improving CLI. What are the top non-medical barriers?

FV: It’s overcoming resistance to new initiatives. A lot of the stuff that’s being done in centers of excellence is threatening to other centers that are not up to that level.

And you’ve got to overcome that resistance. One of the big things is to educate the public about what can be done.

VM: Can the medical community work collaboratively upstream to decrease the factors that lead to CLI?

FV: Yes. I’m a great advocate of medical treatment for arteriosclerosis, statins to control diabetes and blood

pressure. But for limb salvage, arteriosclerosis will occur no matter how you treat the patient. What happens? You give them statins, and they don’t die of a heart attack, so they live to develop critical limb ischemia.

Can you reverse the process? Maybe, yes. Again, that’s a big feature of our meeting. If you drop the LDL, low-density lipoprotein, way down, some arteriosclerotic lesions get better and go away or get smaller. Whether that would stop the CLI or not, I don’t know because CLI is usually due to multiple-level arterial occlusions. So I’m not sure that you could make a difference.

The fact is good medical treatment keeps patients alive so they can develop CLI.

There are dramatic improvements in medical treatment for arteriosclerosis with the PCSK9 inhibitor, Repatha.

And now we have a whole session [at VEITH-symposium] on new drugs, Inclisiran, there are all sorts of drugs which fix your lipids if you have abnormal lipids and keep you alive better.

VM: You have a new book out. It’s called The Medical Jungle: A Pioneering Surgeon’s Battle to Revolutionize Vascular Care and Challenge the Medical Mafia. There is a whole chapter dedicated to limb salvage, which our readers will enjoy. One of the major points of the book is that everything you’ve done, which ultimately proved successful, was initially regarded as heresy.

FV: Human nature is very imperfect. If somebody advocates something new that goes against the grain of cur- rent thinking, the first response is the person is crazy, and it’s not going to work. That is a theme throughout history, which has impeded everybody, impeded progress.

What the book shows is that if you’re persistent, usu- ally you can overcome that resistance. And if you happen to be lucky enough to be right, it gets accepted. And that was certainly true with limb salvage. It was true with the advent of endovascular techniques because we were the first to embrace them, but it wasn’t a surgical specialty. It’s not open surgery. And yet, I was lucky enough to do the first EVAR in North America with Juan Parodi, Michael Marin and Claudio Schonholz.

Juan Parodi did the first EVARs out of Argentina. And when I saw that, I said, “My God, this is going to transform how we treat patients.” Because I knew that our stents were working, even though the surgeons didn’t accept it. I knew angioplasty was working, even though the surgeons didn’t accept it. And here we are fixing aneurysms without opening the belly. And so at the time, I was lucky enough to be the president of the SVS. And that was my presidential address. Why vascular surgeons should embrace endovascular. And I got attacked immersively.

And so that’s in the book. And now, 80% of what vascular surgeons do are endovascular treatments.

VM: Do you have advice for people who are trying to promote new ideas?

FV: Well, it’s a tough question because you’ve got to survive. So it’s a delicate balance. First of all, you have to know that you’re right. You’ve got to make sure that you’re right. You don’t want to advocate something wrong.

And if you’re pretty sure you’re right because of your experience with it, then you just have to be persistent. And not give up just because a paper gets rejected or you get rejected by an important meeting.

I mean, again, it’s an imperfect world. There’s a lot of bias and unfairness. And if you start to be successful, everybody hates you. So that’s one of the downsides. I mean, that’s why I feel very fortunate to get this lectureship while I’m still alive.

VM: I guess you must be very clever to work around that resistance.

FV: You have to be clever, and you have to recognize that your opponents are very powerful.

We were opposed at some points by the president of our hospital. We performed the first EVAR, and our hos- pital didn’t want to promote it. I couldn’t believe it because a good leader glorifies in the success of the people under him. But there are very few good leaders.

The book talks about the frailties of human nature in somewhat of a subtle way. And how do you overcome them? Sometimes you don’t. You have to be lucky.

VM: The politics of medicine is an interesting topic.

FV: Well, it’s like anything else. Human nature cuts across all professions and specialties, et cetera. And it’s not always good. There are a lot of bad guys out there, or they’re temporarily bad.

VM: Maybe we all have a little bad guy in us who creeps their head up now and then.

FV: Yeah. And people do very stupid things often. It’s amazing. And then they try to defend it, and that’s even worse. They don’t admit when they’re wrong.

VM: In another article, Dr. Mark Melin said the ability to quickly recognize when you make a mistake and learn from it is very important.

FV: He’s right. I agree with that; you’ve got to recognize when you’re doing something wrong, and sometimes it’s very hard to do. You’ve got to listen to the opposing views ‘cause they could be right.

The other thing is dealing with adversity, how you deal with adversity, which I never did very well, but I realized the trick is not to be neither destroyed by it nor try to get even; instead you try to just move on. The best revenge is to be successful in your new venture.

I gave a talk at Mayo Clinic ten days ago. They wanted me to give a non-medical talk. So I talked about dealing with adversity and how important it is to success. And I use as an example getting fired, having articles or grants rejected, getting dumped by your spouse, and it’s all the same.

The tendency is to try to get even. And that only makes the lawyers rich. The best thing to do, though it’s hard to do, is to move on. You may find a better job, a better (I don’t want to say better spouse), but a better boyfriend or girlfriend, but that’s a hard lesson to learn. Being persistent and not giving up that’s important too. But there are no secrets to success. I mean, luck is a major factor.

VM: Do you create your own luck?

FV: Somewhat, well, you fall into things. Going to Montefiore, a second-grade hospital, turned out to be in some regards an opportunity. Because Cornell and Columbia didn’t have dedicated vascular services then. They were part of general surgery. Whereas Montefiore was the Wild West and had a lot of poor patients, so you didn’t make much money, but you had some degree of freedom. V

Vein Magazine congratulates Dr. Frank Veith and SVS on the creation of the Frank. J. Veith Lectureship. To get your copy of The Medical Jungle: A Pioneering Surgeon’s Battle to Revolutionize Vascular Care and Challenge the Medical Mafia, visit: bit.ly/MedicalJungle. We look forward to seeing you at VEITHsymposium in New York on November 15 - 19, 2022.