Kieran Das
Twitter: @kieran_das
Vascular surgery is one of the ‘newest’ surgical specialties in existence. Spawning from the recent endovascular revolution, vascular surgery was awarded specialty status in the UK in 2012 (1). Being a new specialty, and with much of the vascular surgery workload composed of conditions associated with the “Western” lifestyle, you might wonder if there is a need for vascular surgery specialists in low and middle-income countries (LMICs).
In recent years however, there has been a noticeable shift in the causes of worldwide mortalities. So called non-communicable diseases (NCDs) such as cardiovascular disease, diabetes and chronic obstructive pulmonary disease now account for two-thirds of global deaths, with four-fifths of these occurring in LMICs (2). Additionally, the unfortunate occurrence of local fighting and industrial accidents in LMICs increase the incidence of traumatic vascular injuries (3,4). Therefore, all these factors combined help to highlight the considerable burden of worldwide vascular pathology.
The rising incidence of vascular pathology isn’t the only reason why it is beneficial to have a readily accessible vascular surgery pool. Moreover, vascular surgeons are also incredibly versatile, equipped with skills that can be used to aid other surgical sub-specialties. For example, their abilities in surgical exposure and control of haemorrhage, especially in emergency settings, are particularly beneficial (5). Therefore, having a group of vascular surgeons is a useful asset, and should be an important consideration for all healthcare systems.
The need for global vascular surgery is evidently growing, and the aim of this article is to highlight some existing barriers to global vascular surgery, and to feature developments that could be implemented to ensure safe and timely vascular surgery provision for all.
Barriers to Global Vascular Surgery
Given the nature of vascular procedures, a particular constraint faced in many LMICs is the lack of training in skilled techniques such as endovascular treatments (6). This, compounded with the limited number of worldwide surgeons and limited physical access to surgeons, exacerbates the burden of disease (7). Additionally, resource constraints are another major problem within LMICs, resulting in a lack of necessary equipment and prostheses for operations (8).
Differences in research output between higher income countries and LMICs should also be considered. The majority of high impact collaborative vascular research occurs in high-income countries, and often is not published in a language other than English (9). This makes it incredibly difficult for LMIC researchers to advance the field of vascular surgery in their own countries.
Advances
Despite these challenges, work has been done to improve worldwide vascular care. Stewart et al. have proposed a set of consensus guidelines for the diagnosis and management of common vascular conditions that should have the capacity to be implemented in resource-diminished settings. In particular, the emphasis is on screening and diagnostics to be conducted at first-point settings, while actual treatment of conditions should be reserved for tertiary settings (10). The benefit of this system is that it allows first-level hospitals to work within their constraints, with referral hospitals providing specialist input. It is hoped that this will provide more focussed vascular care, without necessarily increasing existing costs.
Exchange programmes whereby vascular surgeons from high-income countries swap their activities with their counterparts from LMICs have also been trialled, with Swedish surgeons swapping with their counterparts in Ethiopia. As part of the scheme, procedures were performed and teaching programs conducted amongst other activities. This has been mutually beneficial with Swedish surgeons gaining experience of more open procedures in resource-deplete settings, and Ethiopian surgeons gaining skills in advanced procedures, and communication and leadership skills (11). This mutual benefit highlights the importance of international working, and how all healthcare systems have something to gain by working in this way.
Conclusion
The global burden of cardiovascular disease is only likely to increase in the coming years. Being a relatively new surgical speciality, the barriers to vascular surgery service provision may be even more difficult to overcome than the usual ones encountered in the world of global surgery. However, taking simple steps can improve services without increasing costs. As a global surgery community, we should continue to understand barriers to provision, and ensure that the vascular surgery research community is inclusive of our counterparts in LMICs.
1. Ablett D. The emergence of vascular surgery as a separate specialty: implications for the military. J R Nav Med Serv. 2014;100(1):88–91.
2. Organization WH. GLOBAL STATUS REPORT on noncommunicable diseases 2014 [Internet]. 2014. Available from: https://apps.who.int/iris/bitstream/handle/10665/148114/9789241564854_eng.pdf
3. de Silva W, Ubayasiri RA, Weerasinghe CW, Wijeyaratne SM. Challenges in the management of extremity vascular injuries: A wartime experience from a tertiary centre in Sri Lanka. World J Emerg Surg. 2011 Aug;6:24.
4. Khan FH, Yousuf KM, Bagwani AR. Vascular injuries of the extremities are a major challenge in a third world country. J Trauma Manag Outcomes. 2015;9:5.
5. Powell R, Brown K, Davies M, Hart J, Hsu J, Johnson B, et al. The value of the modern vascular surgeon to the health care system: A report from the Society for Vascular Surgery Valuation Work Group. J Vasc Surg. 2021 Feb;73(2):359-371.e3.
6. Moreira RCR. Critical issues in vascular surgery: Education in Brazil. J Vasc Surg [Internet]. 2008;48(6, Supplement):87S-89S. Available from: https://www.sciencedirect.com/science/article/pii/S0741521408015000
7. Holmer H, Lantz A, Kunjumen T, Finlayson S, Hoyler M, Siyam A, et al. Global distribution of surgeons, anaesthesiologists, and obstetricians. Vol. 3 Suppl 2, The Lancet. Global health. England; 2015. p. S9-11.
8. Edaigbini SA, Delia IZ, Aminu MB, Bosan IB, Ibrahim A, Anumenechi N. Vascular surgeries in West Africa: challenges and prospects. Asian Cardiovasc Thorac Ann. 2015 Jun;23(5):552–7.
9. Ma X, Miranda E, Vervoort D. Placing equity at the core of vascular surgery research. Vol. 72, Journal of vascular surgery. United States; 2020. p. 2220–1.
10. Stewart BT, Gyedu A, Giannou C, Mishra B, Rich N, Wren SM, et al. Consensus recommendations for essential vascular care in low- and middle-income countries. J Vasc Surg. 2016 Dec;64(6):1770-1779.e1.
11. Lundgren F, Hodza-Beganovic R, Johansson M, Seyoum N, Tadesse M, Andersson P. A vascular surgery exchange program between Ethiopia and Sweden: a plus for both. IJS Glob Heal [Internet]. 2020;3(6). Available from: https://journals.lww.com/ijsgh/Fulltext/2020/11010/A_vascular_surgery_exchange_program_between.18.aspx