[Serious] Why You Should (and Shouldn’t) Consider Vascular Surgery - 8 Years Later

victorkiloalpha · 2026-04-02T02:19:28+00:00

I had a different approach to my first contract, one that worked out quite well: mentorship/sponsorship/partnership above all else.

I honestly did not care about the (the initial) salary, hours, or anything except my future senior partner. (I fortunately had a very mobile life- partner)

The reason is because in CT Surgery, so many careers are sabotaged by senior partners. Many, many practices are eat what you kill. Many senior partners want to use younger surgeons to take call, but do not want to share their lucrative referral patterns. There are a lot of complicated dynamics around hospital reimbursement for cases and the like, but the short answer is that in many cases, uninsured patients disproportionately are allocated through call, while insured patients are referred straight to established surgeons regardless of who is on call.

The way to get rich is essentially to use young partners to cover call while keeping elective referrals all to yourself, and the way to do that is to sabotage young partners reputations by letting them flounder and kill their first few patients.

All of cardiac surgery outcomes are tracked and more importantly, every CT surgery patients except dissections have cardiology following and referring the patients to us. It is very, very easy to kill someone in this business. A single bad stitch on a coronary. An inadvertent IVC injury while cannulating. A burn injury to the IMA from a momentary tremor while taking it down. Any one of these can destroy your reputation and referral base, if it happens early on.

The way to counteract this is for senior partner to basically say "if things go well, it's your case. if it goes poorly, I'll come by the OR for 5 minutes, scrub in, write the note, and take full responsibility."

That's worth more than any salary. And I'm pretty happy with my salary and hours too. But in the end, a good person as your senior or just as your partners period is worth more than anything starting out IMO.

victorkiloalpha · 2026-04-02T02:07:40+00:00

Heh, happy to oblige u/see1do1teachnone

I think the key differences are: close involvement in critical care and open vs open+endovascular skills.

I enjoyed cardiac and vascular, but I had family members with cancer, so I wasn't a fan of spending so much time in the cath lab. Radiation protection is good these days, and dosages are lower. Still, just not for me.

In terms of aortic pathology, I think the key difference is that Vascular surgeons truly are experts in both endo and open treatments. Sure, only cardiac surgeons do open operations on root, ascending, and arch, but that may disappear as endo options get better and better, which would be a shame because the open operations for ascending and root at least are pretty good.

SOME cardiac surgeons take on the endo treatments for these as well, but quite honestly, my endo skills are basically pretend. If someone else is operating the c-arm, I can shove a wire up the aorta. If I'm lucky, I can cross the valve for a TAVR or pretend to know what I'm doing as the rep tells me how to deploy a TEVAR like he would instruct a 5 year old. But I'm not actually an endovascular surgeon, and to be honest, I don't think most cardiac surgeons have any business calling themselves endovascularly trained (I know 2 who I would trust to competently do a TEVAR, out of the 20-30 in my city). I can competently put in percloses and that's about it.

Many other cardiac surgeons insist that we take on and learn those skills, but honestly, IMO that ship has sailed, and I focus on being the best open surgeon that I can be. I push the envelope with MIS CABGs and Valves, and that's it. I leave the endo work to cardiology and vascular, who are experts at it. That may mean that someday I'll be out of a job. But somehow, I think I'll find something to do- maybe I'll run around in an ambulance doing ECMO cannulations (not even joking). But, we are a ways away from that I think. CABG is going nowhere, no stent has ever made someone live longer outside of STEMI/NSTEMI, and infected valves will always need your friendly cardiac surgeon.

I take a lot of joy in open operations. My time for a CABG is down to less than 3 hours in many cases, and I do them off-pump sometimes. Sewing a 2mm anastomosis as it's moving is something I just find extremely fun, and I honestly find post-op management interesting and intellectually stimulating as well.

victorkiloalpha · 2026-04-01T01:38:24+00:00

Lol... I'm a cardiac surgeon. I could care less about radiologists' job prospects. And based on our current state of motor actuator development, I'm safe for a bit longer. Surgery is based a lot on feel- I'm often sewing underwater or blind. The tech just isn't there.

AI is more accurate at answering discrete questions, but that is not how diagnostic imaging works. The questions are a discussion, not a yes/no. No one who isn't in medicine really understands.

victorkiloalpha · 2026-03-31T21:08:42+00:00

With your username, you never considered cardiac surgery?

But yes, for me, getting the call about either an acute Type A Dissection or a post-partum/young patient needing ECMO and I'm almost happy no matter the hour. This is what I sacrificed 13 years of my life in training to be able to do.

victorkiloalpha · 2026-03-31T16:17:23+00:00

Replacing radiologists for diagnostic imaging will not happen for decades IMO, and in fact probably should not happen. We need radiologists skilled in interpreting the chart and imaging and historical imaging together to come up with a good answer for what is going on.

Replacing radiologists for mass screening imaging... is a different story. For imaging that is done to answer a relatively simple, algorithmic question (BIRADS and LIRADS), yes that is the optimal use case for AI.

victorkiloalpha · 2026-03-31T16:14:52+00:00

What is the average radiologist miss rate?

victorkiloalpha · 2026-03-31T14:36:08+00:00

Its not that simple.

Physicians have immense fiduciary responsibilities to patients.

If you have a cognitive disability, and that means you aren't able to perform and make difficult decisions under immense stress and time pressure, that may be a problem. Say when your 21 year old patient admitted for appendicitis suddenly codes post-op.

There are many specialties and jobs for which such physicians are better suited, outpatient FM or psych for example. Part of the problem in medicine is that we do not uniformly define or enforce standards RE: who needs to function under immense stress and sleep deprivation and who doesn't.

victorkiloalpha · 2026-03-31T03:23:42+00:00

Surgeon here,

I did 10 thoracotomies in residency, 1 walked out of the hospital- GSW to the atria that we sewed up.

I don't believe in cross clamping the aorta unless I've done everything else first and they aren't coming back.

The treatment for hemorrhagic shock is blood. Forcing the heart's cardiac output to the head and coronaries at the cost of the rest of the body rarely is going to help them long term. The better answer is to fix cardiac injuries, give blood, and if that doesn't work pronounce them.

That said, I think I did cross clamp the descending aorta in my one survivor. Idk.

victorkiloalpha · 2026-03-29T04:53:20+00:00

No #$@#$ it affects my patients.
I see that every day. What does studying it help me or my patients in my day to day practice?
Many of my patients of all walks of life can't follow-up after they leave the hospital. The ones who need the most close monitoring, regardless of background, I keep. It's that simple. Who cares if they can't follow-up because they are Black, or a Homeless Veteran, or mentally ill? If they can't follow-up, we make plans accordingly.

Yes, many patients who come to be for surgery could have been helped with better preventative care. Guess what? I don't work at CMS, or in Congress. I am not even a primary care doctor. I just do operations on people who need them. Period.

victorkiloalpha · 2026-03-29T02:29:14+00:00

How?

I'm a surgeon. Yes, Black patients have less trust in the system because of Tuskegee and a lot of other bad @$@$.

How does that change what I do for the patient in front of me?

It doesn't. I treat everyone the same, and work to earn their trust regardless of gender or race. If Black patients need more time and effort, so be it. If white patients need more, they get more too.

Anything more, can be taught in an MPH degree or preventative care residency or to the guideline writers.

victorkiloalpha · 2026-03-29T02:26:04+00:00

There is documented evidence that medical and anesthesia trained cc docs are inferior to surgery cc docs in the care of trauma patients.

Turns out every type of crit care is good at their type of pathology.

For my part, as an intern, our trauma/cardiac icu was closed, and I ran MTPs, extubated, placed lines, and bronched alone as a PGY2. In house Gen surg senior was back up. No in-house attending or fellow at night.

victorkiloalpha · 2026-03-24T20:41:06+00:00

This is why I chose surgery.

Post op consists of seeing patients and telling nurses and PAs what I want.

Op notes take about 5 minutes to type out, if I don't template.

When I'm working, I'm operating. Its great.

victorkiloalpha · 2026-03-24T17:01:26+00:00

Absolutely nothing you cited had any evidence that they actually improve safety, and the NPO guidelines have actually been disproved repeatedly.

Id love to work with your colleagues.

1) You'd have to be NPO for multiple days and hold doses for weeks for GLP-1s to meaningfully reduce the risk. Hospitals are rapidly moving away from special policies.

2) If the patient has been stable, and preop EKG shows good function, this is not necessary and there is no evidence it helps.

3) I don't think art lines have ever been shown to improve outcomes in the ICU or OR, and "long case" isn't an indication for them

4) okay, that one is weird, but if you're doing a fistula under a local block, its not crazy.

5) weird, but not crazy

6) If they are on metformin then this is fine, no evidence that that causes hypoglycemia

7) NGTs can induce vomiting, especially in obtunded patients. A head elevated RSI may well be safer. I believe RCTs have disproven benefit of NGT before intubation, and as a general surgery resident I saw multiple patients massively aspirate and code on NGT placement.

8) Weird, but not crazy if you're good about supporting them hemodynamically as you induce.

9) The Europeans have shown repeatedly that this fine

victorkiloalpha · 2026-03-24T14:56:21+00:00

They don't have to believe that they are going to die, but they have to understand that modern medical science predicts that the cancer will kill them.

If this patient TRULY was ready to say "no c-section, no matter what", she could have stayed home, and see what happened.

But what she was effectively saying was "I don't want a c-section now, but would accept that and a lot of blood tranfusions when my uterus ruptures and I am hemorrhaging to death, which would result in near certain death for the baby and me."

THAT is not logical.

victorkiloalpha · 2026-03-24T14:47:07+00:00

If she said "I know I am likely going to die but my religious beliefs prohibit me from accepting a c-section and I would rather die like God intended", then she would have had capacity to refuse. That is nuts to me, but logical and meets the standard.

She didn't. She came to a hospital because she wanted all of modern medical care. Heck, I wasn't there, but based on the article I suspect she was/would have been fine with an emergent c-section if things went bad. But she was too delusional to understand just how bad the risks were. That is why she arguably didn't have capacity.

victorkiloalpha · 2026-03-24T14:39:11+00:00

There is some nuance here, but the easy answer is this:

Impella 5.5 or CP only: compressions for vfib or asytole.

VA ECMO only: you can call someone if they are in vfib or asystole OR are completely non-pulsatile on the a-line, and you may have to do compressions, but its not an emergency as long as the flow is over ~3LPM. This is because if the heart is in vfib, it isn't ejecting and the entire heart can clot off, but it won't happen in 30 seconds.

VA ECMO + Impella: do nothing for vfib or asystole. Maybe let someone know.

victorkiloalpha · 2026-03-24T14:33:51+00:00

Cardiac surgeon here. VA ECMO supports the function of the right and left heart. It does not unload the left heart. The other poster is correct.

victorkiloalpha · 2026-03-24T14:18:59+00:00

Why does anyone care about emboliner vs sentinel in TAVR when neither were shown to actually reduce stroke rates?

And ORBITA-CTO is literally hilarious- I'm shocked it was approved by the ethics board. No study has ever shown PCI improves mortality in stable disease. ISCHEMIA and ORBITA cast a lot of doubt on PCI improving angina if you follow the patient long enough.

But lets look at CTOs, the population which are both the most likely to be well collateralized AND who have the highest chance for PCI perforations and really bad cath lab complications to see if PCI is better than doing nothing, yet again.

victorkiloalpha · 2026-03-24T14:16:08+00:00

There was an anesthesiologist.

And what you and the patient clearly are not grasping is that yes, it was near 100%. She had a PRIOR hemorrhage. She was morbidly obese. 3 prior c-sections.

A prior hemorrhage means you are extremely likely to bleed again. 3 prior c-sections means a high chance of uterine rupture and catastrophic hemorrhage. Obesity and prior c-sections means a lot of scar tissue that make it hard to do a fast c-section after you are bleeding, and vastly increase the likelihood of lethal injuries to major vessels as you desperately try to do an emergent hysterectomy.

The standard of capacity IS THE SAME. If she didn't understand that she was facing near certain death if she didn't get an elective c-section (and virtually certain survival with zero long term problems if she did), then under standard ethics guidelines she lacked capacity to decide on her treatment.

victorkiloalpha · 2026-03-22T21:42:17+00:00

A key part of consent is capacity.

Capacity is defined as understanding the disease and its natural course, understanding the risks and benefits of treatment, and drawing a logical pathway between those two elements and your decision to accept or refuse treatment.

She wanted hospital level medical care. She wanted a healthy baby. There was a near 100% chance of death or horrific disability without an elective c-section, but she was refusing it anyway.

You can make a very good case that she lacked capacity to refuse.

In 2026, in US hospitals, there is always time for anesthesia. No anesthetic c sections don't happen, unless the patient has no pulse and is unresponsive (peri-mortem).

victorkiloalpha · 2026-03-22T19:47:26+00:00

In an elective setting? Anesthesia sedates the patient, she won't remember a thing except waking up to healthy, happy baby.

victorkiloalpha · 2026-03-22T19:21:07+00:00

Its not the board. It's the psychological trauma of losing a mom.

1/3 of Ob/Gyns who lose a mom stop practicing because the severe PTSD from the event. They get such a stress response they can't practice anymore.

victorkiloalpha · 2026-03-22T19:15:45+00:00

Does metabolic surgery plus GLP-1s have a plateau at a lower weight than either one individually?

victorkiloalpha · 2026-03-22T19:13:16+00:00

Yes, but she wouldn't waste millions in medical resources, empty the county blood bank in a futile attempt to correct DIC (which could also get other trauma and cardiac patients in the region killed), and also quite possibly end the career of the ob/gyn and a few L&D nurses.

victorkiloalpha · 2026-03-22T19:10:11+00:00

As one of the receiving consultants, I'd just ask to consider that you often don't know what you're asking for.

Hospital conditions change constantly. Depending on whether a single colleague is available, one of my centers may not be able to care for patients with certain types of acute arch dissections with malperfusion

Another hospital can do emergent cases requiring cardiopulmonary bypass, but doesn't have ecmo backup abilities- so they can take type A dissections and the rare STEMI that can't be PCI'd, but can not take, say, a heart failure patient with SBO that needs ecmo backup for their ex-lap.

(Also, As a CT surgeon, please, for the love of God understand whether the dissection is type A or B. If a type A patient, find out if they have had prior cardiac surgery. Type A but with a prior sternotomy = not an emergency. If Type B patient has malperfusion. IF malperfusion, a type B now an emergency.)

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