The aorta is not only the largest blood vessel in the human body – it also symbolises the emotional, political and structural tensions within the field of vascular surgery. In this episode, Dr Farzin Adili talks to Prof. Dittmar Böckler, Medical Director of the Department of Vascular and Endovascular Surgery at Heidelberg University Hospital, about key developments and challenges in aortic surgery.

The discussion centres on fundamental questions: What does it mean when the aorta is suddenly defined as an ‘organ’? What implications does the Hospital Care Improvement Act (KHVVG) have for the future of aortic surgery in Germany? And: How do we safeguard training and the next generation of specialists in a field that is becoming increasingly centralised and technical?

In addition to structural and systemic issues, the discussion addresses specific clinical decisions: When are fenestrated and branched endoprostheses justified in patients over 80? What role does biological age play in determining indications? And how can augmented reality, AI and simulations improve training?

An in-depth discussion on the past, present and future of a cornerstone of vascular surgery – entirely in keeping with the DGG motto: “We take vascular thinking further.”

Topics in this episode:

• Why the aorta is so emotionally charged – and what that means for vascular surgery
• Aortic surgery as “organ medicine”? Criticism of new guidelines
• Minimum case numbers, centralisation and structural requirements
• Age, comorbidity and individual treatment decisions
• Endovascular procedures in the very elderly
• Challenges in further training and recruitment of young talent
• Simulation, digitalisation and AI as future prospects

Questions or feedback? Would
you like to get in touch with the editorial team or the experts? We look forward to hearing from you at: podcasts(at)medizinkommunikation.org

Adili: Welcome to a new episode of ‘Vessels in Focus’, the podcast of the German Society for Vascular Surgery and Vascular Medicine. Here we discuss the latest developments, challenges and opportunities in our field. Today’s topic is aortic surgery, emotion and evidence. My name is Farzin Adili. I am Head of the Department of Vascular Medicine and Vascular Surgery at Darmstadt University Hospital, currently President of the German Society for Vascular Surgery and Vascular Medicine, and one of the hosts of Gefäße im Fokus. Today, I am particularly delighted to welcome my long-standing friend and colleague, Prof. Dittmar Böckler, Medical Director of the Department of Vascular Surgery and Endovascular Surgery at Heidelberg University Hospital.

Dear Dittmar, it’s lovely to have you here.

Böckler: Thank you very much, Farzin, for the invitation. I’m very much looking forward to our discussion today.

Adili: Dittmar, you are undoubtedly one of the leading experts in aortic surgery, and anyone involved in vascular surgery knows that the aorta is one of our key areas of work. Some even refer to it as a separate organ. We may come back to that later. In any case, it is certainly an area of our work that we approach with great passion and frequently discuss at conferences and meetings. And that’s exactly where I’d like to start. Why does aortic surgery play such a major role in our speciality, and why, in your view, does it affect us as vascular surgeons so deeply?

Böckler: Yes, dear Farzin, aortic surgery does indeed play a very significant role in vascular surgery, even though, historically speaking, it originates from cardiac surgery. I would like to mention Charles Dubot, the French surgeon, who performed the first aortic interposition in 1951 using a homograft, and then Michael DeBakey, who performed the first Dacron interposition two years later. However, as you know, a revolution has naturally taken place over the last 20 years, namely endovascular therapy, which we abbreviate to EVA. And this endovascular therapy has, I believe, significantly influenced and changed our perspective and our relationship with aortic surgery. Namely, we have adopted and implemented this technique – in contrast, and this can be said openly, to cardiac surgeons who have not dared to take this step – and have made it a complementary method in the treatment of aortic diseases and aortic aneurysms. And I believe that was a decisive step, which now enables us to treat patients in a truly multimodal and, above all, personalised manner. I believe that was a huge step. We conducted the necessary studies. I’d mention EVA I and DREAM, but also UK, the Aneurysm Trial. All these studies built up scientific evidence that we were able to use to then become the leading discipline in treatment.

And since you mentioned emotions, surgeons do tend to define themselves through major operations. Cardiac surgeons, bypass surgery, aortic valve surgery, transplantation, vascular surgeons, perhaps the Vipershaw procedure. And for us, it’s aortic surgery, because it’s naturally fascinating and incredible when laypeople hear that we clamp off the aorta, cut through it and replace it. But I’d also like to say at this point that aortic surgery is only one part of our speciality. You know that just as well as I do. And I believe that success in aortic surgery cannot be explained purely in emotional terms, by saying it’s a major operation; rather, it naturally depends – and we’ll come to this in a moment – on the structures, the infrastructure, the human skills, and interdisciplinarity. I think we’ll touch on that again shortly. But that, I think, is the emotion surrounding the aorta. Yet I’d like to put it into perspective and cast it in the right light. Because we mustn’t in any way rank carotid surgery, and above all peripheral bypass surgery and AVK therapy, internally here.

Adili: As you know, at the start of last year there was a new international guideline from the US and also from the European Thoracic Society that made the aorta an organ – we’ve also spoken of it as having been ‘elevated’ to that status. How do you view this? From a professional perspective, can you agree with this framing, which is now primarily shaped by cardiac surgery? Or how would you like to categorise it?

Böckler: In my view, describing the aorta as an organ is not correct. After all, the human body’s largest blood vessel is a vital conduit that carries blood to the organs. By definition, organs are structures that perform functions and consist of multiple components, such as muscles, bones, and so on. And I don’t believe the liver and the lungs are comparable to the aorta. Here, an attempt was made to bring together the complexity of aortic diseases – from inflammation and tumours to degenerative conditions – under one umbrella. And this, shall we say, political move by cardiac surgery was, in my view, also in their own professional interests. I can say that quite openly. That is my personal opinion. Because we have, of course, conquered the aorta, from the internal aorta up to the thoracic aorta, and have now reached the arch. We can treat open and endovascularly, we can treat conservatively, we can screen. And that is why, I believe, a certain struggle has already arisen here, a certain competition, although I am of the opinion that cardiac and vascular surgeons really must work together, particularly in the aortic arch and in thoracoabdominal surgery. So I don’t think much of this initiative, and purely from the vocabulary, from the definition, the aorta is not an organ.

Adili: Well, given that no truly reputable vascular surgery society was involved in the guidelines that were published, it suggests there is an agenda behind them that goes beyond the purely technical. And as a professional society, we have explicitly commented on this.

Böckler: Farzin, I hold guidelines in high regard; we need them. They form the basis of our medical practice and are also crucial for decision-making regarding what we can, must and wish to offer a patient. But no other guideline – there is the European one, the American one, and the German one is currently being revised – has used this term ‘organ’. It’s about aortic aneurysms; it’s about dissection. And the guideline in question, which you’ve just cited, is a guideline produced by a group of highly respected colleagues who came together to compile evidence, but in my view also to send out a certain political message. None of the other guidelines from the other professional societies take this step. And I think that says it all and answers the question: this is about more than just politics. It’s about our patients and providing good care.

Adili: Yes, I don’t think there’s anything more to add to that. Perhaps let’s delve into the systemic aspects again. One reason why aortic surgery is being discussed so intensively at the moment has to do with hospital reform. Yes, to be more precise, the Hospital Care Improvement Act. A very unwieldy term. This law calls for greater centralisation, minimum volumes, and there is also an explicit service group: abdominal aortic aneurysm. What do you think this hospital reform will mean for the implementation of this service group for aortic surgery in Germany?

Böckler: Perhaps first of all, this planned and already initiated reform will, of course, definitely have a major impact on the care of patients with aortic diseases. To begin with, this unwieldy law – or rather, this unwieldy name – naturally has ambitious goals, but at the same time significant limitations. Officially, as you yourself said, the aim is to improve the quality of treatment. I’ll get to aortic surgery in a moment. On the other hand, the aim is to provide optimal care across the board. We all know how difficult that is. We have regions with over-provision, we have regions with under-provision, and the aim is also to reduce bureaucracy in hospitals. Quite honestly, between us or here on the podcast, this naturally also has to do with funding and limited resources. Now, of course, when we turn to the aorta, this naturally has implications for the aforementioned service group 12.1 for abdominal aortic aneurysms. Incidentally, all the other aortic conditions – and there are so many of them – aren’t even taken into account. This whole system doesn’t incorporate the interdisciplinarity and multidisciplinarity required in the treatment of aortic patients, nor does it address the structural requirements.

We naturally face the risk of underprovision if we centralise. I believe we should discuss the issue of centralisation in more detail again. I was and still am a staunch supporter of centralisation, with all its ins and outs, if I may put it that way. It must be done with great care. The DGG has, of course, already taken a stance on this. Minimum case numbers alone, dear Farzin, do not, in my opinion, do justice to the requirements that this law has and brings with it. We have defined minimum case numbers in the guidelines. We have defined minimum case numbers in our awarding of the RAL quality seal for aortic centres, and we are well aware of the debate surrounding minimum case numbers. This is always a very challenging basis for discussion. I am of the opinion that complex aortic surgery and open surgery should definitely be centralised. This is also reflected and confirmed in the guidelines. And I think that, given the low case numbers – again, we are talking about a field of medicine and vascular surgery that is not performed as frequently as other procedures – centralisation makes sense for the reasons we are aware of, in terms of optimal patient care and quality control. One final point is training and further education. If we want to offer this form of medicine at the highest level in future, we must also ensure further training. And further training also has to do with ‘volume’ – that is, a minimum number of procedures. Otherwise, we cannot prepare the next generation for the future.

Adili: Yes, we’ll come back to the next generation in a moment. You know, this is an issue that is very close to my heart too. I’d like to briefly return to the care of patients with aortic pathologies. Demographics are clearly moving in one direction. We’re all getting older, and our patients are getting older too. And endovascular aortic surgery in particular has proven to be associated with particularly few complications compared to open surgery, so naturally the threshold for treating even very elderly patients is gradually lowering. In the last podcast episode, we discussed carotid surgery and the question of whether carotid stenoses should be treated in older people. At this point, a shout-out to Barbara Rantner and Lars Kellert. A question came up in the feedback. Yes, the carotid issue is certainly interesting, but what about fenestrated and branched endovascular prostheses in the treatment of thoracoabdominal aneurysms in patients over 80? I know that in some centres, these patients are completely excluded from open surgery – in other words, they are no longer considered at all due to their age. How do you view this in relation to endovascular surgery? Would you take the same view, or do you have a different approach to this?

Böckler: That is a very interesting and very important question in everyday clinical practice, which my colleague raised and which you are bringing up again here. Age is quite clearly a very, very important parameter in determining the indication for aortic diseases. Let’s stick with aortic aneurysms for now, and I’ll get straight to the complex fenestrated and branched endoprostheses. Age, as we know, is an independent risk factor. And we also know – I believe this is the case everywhere – that the older a patient is, and probably the more comorbidities they have, the more likely they are to be treated endovascularly. But then we face the limitations of anatomy, and not all cases can be treated endovascularly. We want a good outcome; we need good long-term results – it’s not just about 30 days. That is why anatomy is just as important as clinical factors, including age. There is good evidence – as is also the case in carotid surgery, incidentally, and in aortic therapy for aortic aneurysms – that octogenarians, i.e. those over 80, can be treated effectively and, if they have a good prognosis and a correspondingly low risk profile, should indeed be treated. What I’m trying to say is that, as a matter of principle, one shouldn’t deny a patient treatment simply because of their age, or say that endovascular treatment is the only option for them. There are so-called risk scores where age plays a major role. These can serve as a guide. They don’t answer every question, however. Ultimately, it comes down to an individualised treatment decision: which patient is sitting in front of me, and how good are our own results? Exactly two weeks ago, I operated on a patient who came in at 4 pm with a symptomatic aneurysm; she was 90 years old and underwent open surgery, and this was not an isolated case. Of course, it went well. There are such individual cases, and we both know that there is a difference between chronological and biological age. So there are 60-year-olds who are as unwell as 80-year-olds, and vice versa. There are 80- and 90-year-olds who are fitter than 60-year-olds. That is why age in itself is not an exclusion criterion, but rather it is factored into the decision alongside the patient’s wishes, feasibility, endovascular versus open surgery, and comorbidities and associated risk factors.

On the question of fenestrated stents and fenestrated prostheses, I must say that things become somewhat more precise and complex, as we are talking about a very expensive and very complex procedure. It isn’t done in an hour, like a normal EVA, but takes three or four hours. We have reintervention rates of 10 to 15 per cent, and if you look at the data now – there is very recent data from the USA – a large consortium analysed 1,500 patients who had undergone fenestrated treatment in America, and this shows that the underlying disease itself carries a poor prognosis. Fifty per cent of these patients are no longer alive after five years, regardless of the aorta. They die from other causes, from other illnesses, and I believe we must take that into account. Admittedly, the prognosis is difficult to assess. We are not clairvoyants and do not have a crystal ball, but we know that such a complex and also expensive treatment method, which also places a burden on healthcare costs, must be selected very, very, very carefully. At the end of the day, it remains an individual decision based on the centre’s findings and experience, the patient’s treatment preferences of course, the anatomy, and the associated risks. In principle, I would not exclude a patient from treatment. However, we must factor into the decision-making process that these patients do not have a long life expectancy. We know from American study data recently published that 50 per cent of patients with thoracoabdominal aneurysms and pararenal aneurysms are no longer alive after five years. And these patients die from other causes, mostly cancer or heart attack, and not from the aorta. And that is why this decision-making process is a very fine line that we are treading.

Adili: Yes, I basically see it exactly the same way as you do. Chronological age is, of course, a surrogate for comorbidity, but nothing more than that. And one must consider it on an individual basis, and I wouldn’t do that either. Now, of course, the criticism often comes from proponents of centrally organised healthcare systems. We do, after all, have one of the most decentralised healthcare systems in Europe, and also the largest. And we perform a great many aortic operations. We also perform a great many aortic operations beyond age restrictions and even size specifications. Aneurysms are, after all, not infrequently smaller than the 5.5 centimetres required for infrarenal abdominal aortic aneurysms in men. How would you put that into perspective? I mean, from an economic point of view. We are, of course, first and foremost doctors. And it’s about people and it’s about medicine. And yet the economy always plays a role, a kind of background noise. You yourself have just said that the prognosis for patients with aortic aneurysms is not so much determined by the aortic aneurysm itself – that is, aneurysm-related mortality – but rather by frequently accompanying conditions. So, against the backdrop of economics, what would your stance on this be? How would you classify this?

Böckler: Farzin, you know, of course, that this question cannot be answered from a purely economic perspective. And I will, of course, come back to your question. Nevertheless, I would like to point out that, from a medical and epidemiological perspective, we know that, firstly, the prevalence and incidence have been declining since the 1980s. So aortic diseases are becoming less common. Patients are showing increasing compliance with drug therapy. That is to say, statin therapy – which we know can reduce, though not prevent, aneurysm growth and rupture – is accepted in society. That certainly requires patient management and a good approach. And rupture rates seem to be falling. That is why the threshold for treatment has been raised across Europe. We used to start operating at 5 cm, as you’ll recall. And now we’re at 5.5 cm, and for iliac aneurysms even at 3.54 cm. And for thoracic aneurysms too, with the exception of women and patients with connective tissue disorders, the threshold—that is, the limit—is slightly lower. And we’ve deliberately raised that because the risk of rupture or rupture-related death has fallen over the last few decades. And against this backdrop, of course, from an economic and health policy perspective, we must strictly adhere to guidelines and recommendations. So I don’t believe in implanting a prosthesis just because I can and because it’s easy to treat, especially if it’s only just covered by Eva’s insurance. As doctors, we certainly have a medical responsibility. I don’t think we need to #db0723 about that. But we also have an economic one. I’m not saying that we must be guided by the hospital administration’s budget when determining indications, but first and foremost – and this is what I wanted to emphasise – it is the evidence we have regarding the condition: natural risk over time versus the risk of the procedure. And then, of course, we have to factor in the costs of treatment. And one thing mustn’t be forgotten, particularly with endovascular therapy, Farzin: reinterventions are still at ten to twelve per cent. The rate of readmission to hospital is high. And we mustn’t just think about the primary procedure, but about the long-term outcome. We want a long-term, sustainable, effective treatment. And we cannot afford to have patients coming in for a CT scan every year, with one in eight patients ending up back on the operating table within the first three years. That makes no sense medically, nor economically. So we need to bring these discussions together. They must not be conducted separately, because we are, first and foremost, doctors, not economists, yet we bear responsibility for both.

Adili: Yes, I really can’t add anything to that. So surgery with a sense of proportion, without a doubt, and I really shouldn’t say this out loud, but under no circumstances would I issue an indication for the hospital for any economic reasons that I don’t support medically. You’ve just mentioned demographics and the declining incidence and prevalence of aortic aneurysms. And that naturally presents us with a different challenge now. In Germany, for the infrarenal aorta, the ratio between endovascular and open surgical treatment is now shifting sharply towards 80-20, that is, 80 per cent endovascular and 20 per cent open surgery. In some hospitals, the situation is different. We still perform significantly more open surgeries, and in the case of younger patients, we are actually performing open surgery more and more. But across the board, it must be said, we are moving towards an 80-20 ratio. And in some hospitals, open aortic surgery is actually no longer really part of the portfolio. This can be classified as occasional surgery. What naturally concerns me, as someone deeply involved in training and continuing professional development, is how we can secure the future of training in open aortic surgery with such case numbers, with such figures for open surgery? How do you think that’s possible? Is it even possible anymore? What approaches do you have in Heidelberg?

Böckler: You’re raising a crucial issue for the future; in fact, if we don’t take care of the training and further education of the next generation, we’ll run into problems. And as you quite rightly said, open surgery remains a complementary treatment option. For what I believe is still a relatively large number of patients – you just mentioned a ratio of 1 to 4, 1 to 5. And that is why we must provide training in open aortic surgery. Endovascular procedures can probably be taught more easily using simulators. In open surgery, particularly regarding access, the training is naturally more demanding. I think it starts with recruiting the next generation. Quite simply, without new recruits, we needn’t even worry about how we intend to provide further training. And one thing does not exclude the other; they are interlinked. If we have good training and further education, and offer a sound programme for this multimodal medicine, then we will also attract new talent and bring them into our speciality. So we need comprehensive, yet realistic, training and continuing education concepts. You’ve always worked very hard on this. These are curricula and appropriate training centres that, quite frankly, offer both – or not just both, but everything else too: diagnostics, screening, ultrasound diagnostics, as well as research. So it’s about more than just offering open surgery. And to be honest, that brings me full circle: I need a certain healthy, sensible centralisation, because without a certain volume we cannot teach. The days of ‘see one, do one, teach one’ – that’s how I grew up. I watched, and at some point I was allowed to do it – or rather, I had to do it at night because nobody taught me during the day. That was a terrible time. Thank goodness that’s over. I think you, as an educator, can confirm that. And it has to stop. We can’t train people like that anymore. We need curricula. We need clear concepts that can be implemented. And we need methods. In my view, and we’ve introduced this in Heidelberg – since you asked me – we need so-called skill labs, where you learn to operate on a perfused model, learn suturing, learn anastomoses. You can borrow simulators with the support of industry partners to practise endovascular techniques. But we also need to integrate science into this training. Digitalisation and AI – that is a completely new topic which we probably won’t even cover today. What role will AI and digitalisation play in the training of the future? And to really make all this a reality, against the backdrop of a consolidation of vascular medicine – think performance groups and centralisation – we will have to create training networks. In other words, cross-site training networks where open surgery is offered alongside endovascular therapy. We need clinical shadowing placements; we need fellowship programmes. The Americans already have this. I believe the British do too. And we need structured rotations. So, a long wish list that we do not yet have. We have started this in Heidelberg. Smaller hospitals refer patients with aortic aneurysms to us, and the senior registrar or the advanced trainee joins the operation to assist. They won’t be performing the surgery, but they will assist. Because in their home hospital, they don’t do it themselves. But they learn the basic principles. And I think you can say more about that than I can. Medicine, vascular medicine, must be taught at specific levels of competence. And not all levels of competence need to be offered everywhere. So, quite specifically, we have introduced an initial rotation training post in Heidelberg. It lasts a year, and we now even have applicants from Switzerland. And they come to us with a focus on aortic surgery. That builds trust, and with the smaller hospitals, this exchange creates a win-win situation. And, last but not least, at the end of the day, it is the patient who benefits from it. I am

Adili: Well, I absolutely agree with what you’ve said. But I’d actually like to take it a step further and think about simulation again. To be honest, I believe that in future – to use an example from aviation – we cannot, or should not, train or further train our colleagues on how to extinguish an engine fire at the very moment the fire breaks out. What I mean is, for many scenarios we encounter, particularly in open surgery and open aortic surgery, where our simulations – as far as they are currently available – do not yet provide the right answers, I believe we must not be satisfied with this level. And my view is that we need to engage much, much more intensively in research and science in this area, and perhaps even set up start-ups, to improve the quality of simulation in surgery. We need to increase responsiveness – that is, how the system reacts to an intervention – in order to train and practise for scenarios for which we essentially have no models at all. You know, there’s a quote from that well-known American textbook: ‘The operation of a ruptured AAA is like a well-orchestrated ballet in a bloody combat zone.’ And it is precisely this kind of combat zone that we have not yet been able to simulate, but that is where we need to get to. Of course, this isn’t something for today or tomorrow, but for the day after tomorrow; however, it requires our expertise as clinical specialists and the relevant IT specialists to develop something like this. And I believe that this is also an important element alongside what you said – and I can only wholeheartedly agree with that – in order to improve teaching and training, further education and professional development in this field.

Böckler: Let me add something to that. I’m fully on your side. We need to look to the future and become more innovative in teaching and continuing professional development. One principle remains, however: surgery is also a medicine of experience. That means that anyone who isn’t in the operating theatre over the years won’t experience the complications – which aren’t always avoidable – and probably won’t be able to improve their skills and competence through experience either. So, of course, it remains a practical profession that cannot be fully simulated. But what you can do – and you’ve already mentioned this – and I’d like to illustrate it again with two examples, I think, is use the new technology and innovations coming our way to be prepared. Take augmented reality and cloud-based artificial intelligence, for example. Augmented reality, using glasses and CT fusion, can show the anatomical structures before you’ve even dissected them. So you look into the surgical field and, through the glasses, you’ll see the renal vein before you dissect the aorta at the upper neck. And I do believe that such technology also helps to avoid complications such as bleeding. And the second example would be cloud-based big data analysis. If we send the information we generate in the operating theatre to a cloud, then it will be possible there for computers – high-performance computers – to analyse this data, as we know, in seconds or milliseconds, and provide us with feedback. They will discover digital twins – that is, people who are five years older, or patients who underwent surgery five years ago, in the same situation with the same morphology – and then there will be a kind of feedback to the surgeon: “Dr Adili, you operated on a case like this three years ago. You won’t remember it because you simply do so much, and the human brain does have its limitations after all. In that case, a Type 1 endo-leakage remained. So do consider whether you really want to place the prosthesis there.” That sounds very fictional now, but I’m sure it will happen. And that too will help us to #db0723reduce complications, improve outcomes and modernise training and

Adili: Very good. Yes, I can well imagine that. Dear Dittmar, we’ve essentially covered all the key topics. That was a very intensive and open discussion. Thank you very much for that. Perhaps a brief summary from you. What do we need for a bright future for vascular surgery in Germany? In a nutshell.

Böckler: Vascular surgery – and I include endovascular therapy in that – is a highly attractive speciality with a secure future; we will ensure that. Not just against the demographic backdrop. To safeguard vascular surgery and aortic surgery – let me summarise this collectively – we need young people; we must nurture the next generation who are enthusiastic about the discipline. For the aorta, for vascular surgery as a whole, for this profession. And, of course, we also need equally committed and competent young professionals in nursing to be able to achieve this together. Multimodal aortic surgery can only be done as a team. We need excellence through structure, through the further training we have discussed. We need healthy self-confidence, but the whole thing can only be underpinned by quality. We cannot simply claim authority. We must deliver and do our homework. We must make use of innovations, as just mentioned, AI, and always think positively about change in society and in healthcare. I believe our discipline must be portrayed in a positive light. There are always crises in the world, and we were recently talking again, Farzin, about quotes. We both know and like to quote Winston Churchill: “Never let a good crisis go to waste”. And in German terms, never let a crisis pass you by unused. What I mean is, we will face crises, we will have discussions, but we must emerge from them stronger and with a positive outlook. I believe the professional association is well advised. Our discipline is very well advised: if we work together here to promote continuing education, quality and multimodality in aortic surgery, do our homework and pursue the right goals, then I believe aortic surgery is, as it is today, in the right hands here, for the benefit above all of our patients. That is what matters most of all.

Adili: I can’t and don’t want to add anything more to that. Thank you very much, dear Dietmar, and to our listeners – it’s been lovely having you with us. We’d be delighted if you could give us some feedback, and if you have any questions, please send them to us. As you’ve seen, we’d be happy to feature you in one of our upcoming podcast episodes, if it suits. Please feel free to send us a short email to podcasts@medizinkommunikation.org. I’d be delighted if you’d stay tuned and subscribe to the podcast on your preferred platform. Then we’ll catch up again in about a month’s time. Stay curious, critical and committed to vascular medicine. Until next time on ‘Vessels in Focus’.