Adili: Welcome to a new episode of ‘Vessels in Focus’, the podcast of the German Society for Vascular Surgery and Vascular Medicine. My name is Farzin Adili; I am a vascular surgeon at Darmstadt University Hospital and the current President of the DGG. This podcast is designed to provide you with a platform to delve deeply into the topics of vascular medicine. Together with our guests, we will highlight the latest developments in surgical, endovascular and conservative vascular medicine and discuss current topics from science, teaching, clinical practice and the professional field, true to our motto: We take vascular medicine further. For today’s podcast episode, I have invited two guests. Professor Markus Steinbauer, Head of the Department of Vascular Surgery at the Hospital of the Brothers of Mercy in Regensburg and Past President of the DGG, and Dr Hartmut Görtz, long-standing Head of the Department of Vascular Surgery at Bonifatius Hospital in Lingen and current Treasurer of our professional association. A very warm welcome to you both.
Görtz: Thank you very much for the invitation, Farzin.
Steinbauer: Thank you, it’s a great pleasure.
Adili: Today we will be discussing the topic of vascular geriatric medicine. Vascular diseases are, after all, primarily diseases of old age, and according to the Federal Statistical Office, there are approximately 19 million people aged 65 and over living in Germany. That is around a quarter of the total population, and this proportion is also steadily increasing. At the same time, we currently have around 1.8 million people in Germany diagnosed with dementia, and this figure rises by around 400,000 each year. We also have a large number of patients with vascular diseases alone; for example, 2 million people suffer from peripheral arterial disease (PAD).
Our therapeutic measures, whether interventions or operations, are becoming increasingly gentle and technically perfect, but just because we are capable of doing something does not automatically mean that we should do it. And that is precisely what I would like to discuss with both of you today.
Markus, you have worked extensively on palliative care in vascular surgery, and you, Hartmut, have done a great deal of work on endovascular techniques, helping to develop and train others in them. So you both represent a high level of technical expertise, but also a sense of responsibility.
Hence my first question: when it comes to very elderly patients, what is the greater challenge today – the technique or the decision? Would you like to start, Markus?
Steinbauer: Gladly. I increasingly think, however, that it’s an issue we’ve been grappling with for a long time: is patient-centred care decisive, and in that respect, is technology – and the best possible technology – a prerequisite? But fundamentally, the greatest challenge is, of course, the decision: what can, should, or do we want to offer the patient? And the second is: what makes the most sense from the patient’s perspective.
Görtz: Well, I basically see it exactly the same way. Of course, the gentle, minimally invasive technique is often a technical challenge. No question about it, but that is a challenge we as surgeons have quite deliberately chosen. That is why we became surgeons in the first place.
But for me, too, determining the indication is actually the supreme discipline. So to what extent does the patient benefit, what are the advantages and disadvantages of the procedure, and what impact will it have on their life? And that is, of course, particularly important in the group of the very elderly. That is, this group with potential cognitive vulnerability. Surgical techniques are often standardised, but determining the indication – and here I fully agree with Markus – must always be individualised, and that is actually the major challenge.
Adili: Yes, otherwise we end up with ‘operation successful, patient dead’, to put it succinctly. A delicate matter.
We often talk about biological age. But what does that actually mean? Markus, when an 88-year-old is sitting in front of you, what do you look at first? Is clinical experience enough, or do we need structured geriatric assessments?
Steinbauer: Ultimately, we don’t just start looking at the patient once they’re seated. They enter the consultation room; the patient’s mobility alone, but also the way the conversation flows – that is, a clear perception of the patient’s abilities, cognitive abilities and linguistic skills – are important, and ultimately this overall assessment is very revealing.
Nevertheless, it is also occasionally useful, in the case of patients with limitations, to involve their environment, relatives or their wider circle; and although one may have, or will acquire, clinical experience with age, it is nevertheless the case that a structured geriatric assessment is, in my view, absolutely essential for patients who have limitations in terms of mobility, cognition, but also, so to speak, frailty, is, in my view, absolutely essential.
Görtz: Well, I see it that way too. The clinical perspective is certainly correct, and that is something which clinical experience also reflects, but of course, even with a patient suffering from heart failure, a clinical examination reveals that this patient clearly has heart failure. Nevertheless, we naturally make the effort to try and quantify this. That is, after all, part of modern science; so we must, of course, measure the ejection fraction, for example, or perform an ultrasound scan of the heart, or we must assess renal insufficiency by measuring creatinine and urea levels. But when considering older patients, functional limitations are, of course, crucial, and we have the assessment tools developed by geriatricians, which we should definitely use, as this is decisive for the next steps. Depending on the results, we may, of course, decide against surgery in some cases, or we may downgrade the procedure – for instance, performing a single-stage reconstruction instead of the two-stage reconstruction that was originally required or planned.
But it may just as well be that an elderly person sits there and says, ‘I actually don’t want to have an operation at all’, and we come to the opposite conclusion based on our assessments and say: ‘Based on everything we know and have examined, you are actually at the stage of someone closer to 70. We can reasonably expect you to undergo the operation, so that’s one way it can go; it works both ways. It can lead to a decision against surgery, but also to a recommendation for surgery. In that respect, I believe the assessment is important.
Adili: Is chronological age ever an exclusion criterion for you, Hartmut?
Görtz: Chronological age is… not a deal-breaker from the outset. It is an important criterion, but the truly important criterion is biological age. And here it is crucial to understand that ageing simply means a cumulative decline in multiple physiological systems – in other words, a state of reduced reserve and reduced resistance to stressors. Knowing this is absolutely crucial, because if we know that functional age – functionality in old age – is reduced, then we can draw the appropriate conclusions, for there are, after all, the fit elderly, whom we sometimes call ‘Go-gos’; we recognise them relatively quickly in our consultations – for instance, the 80-year-old patient who sits there and says: ‘Oh, I climbed a two-thousand-metre peak just two weeks ago.
But of course we also know the ‘no-gos’, who are brought in on a stretcher because they are no longer able to walk, because they are bedridden.
But the difficult group is the one in between, and there it’s absolutely crucial to know what their biological age is or what their functional age is. And in the studies, this correlates significantly with the outcome of our procedures.
Adili: Let’s get specific. Markus, consider the following scenario: an 88-year-old man with a 5.8-centimetre infrarenal aneurysm; the gentleman is mobile with a rollator, has mild cognitive impairment, and no other complaints. Would you treat this endovascularly?
Steinbauer: I would probably opt for neither endovascular nor surgical treatment, but would likely continue to monitor the patient, because the likelihood of him suffering a rupture is significantly lower than the endovascular risk; and in this respect, particularly for patients with a somewhat limited life expectancy, the main consideration with preventive procedures is: does it actually make sense to perform an intervention or operation at all?
Once we have a clear decision here, it is still important, so to speak, to ask: where is the risk and where is the benefit for the patient?
Adili: So, you really have to consider what the actual therapeutic goal is?
Steinbauer: Alongside the determination of the indication, so to speak, the defining of the individual treatment goal is crucial, particularly in older or geriatric patients.
Adili: Hartmut, would anything argue against an intervention in your view?
Görtz: Well, I would take exactly the same approach as Markus. I would initially adopt a wait-and-see approach with this patient, although life expectancy is, of course, a very important factor. But another important factor is that, according to studies, the complication rate of endovascular procedures in very elderly patients who are frail is roughly two to three times higher than in the general population. And since the indication is naturally linked to the complication rate, one must of course consider whether 5.5 or 5.0 centimetres is the correct size for an abdominal aortic aneurysm.
The working group from Düsseldorf has now published this, or will do so shortly.
Based on this group’s findings, one might perhaps lean more towards 7 centimetres rather than 5.5 centimetres. So, I would definitely wait and see for now, continue monitoring the patient, treat them with statins of course, and then see how things progress.
Adili: In the event that we both actually decide against invasive treatment. In such a situation, would you actually speak openly with the patients and their relatives about the limited life expectancy, or how would you approach it?
Steinbauer: It’s less of a conversation about limited life expectancy. It’s more of a discussion about what one would do if a rupture were to occur: would one then take on an even greater risk as a patient, and would one possibly end up in the emergency department of a hospital, or would one prepare the entire situation—the patient, the relatives and the GP care—for the possibility that the patient might not wish to undergo surgery at that point.
Adili: How would you organise that in practice? Because there are quite a few practical things to consider; if the patient has acute symptoms, many people find themselves in a bit of a panic and immediately dial 112, and then, not infrequently, the inevitable takes its course. How do you prepare for this, and what needs to be considered?
Steinbauer: Well, we usually start with a discussion with the patient and their relatives, and then involve the GP, who is generally the point of contact and can then make decisions regarding the home situation. Should an emergency doctor be called at all?
And secondly, if desired, palliative care services such as a specialist outpatient palliative care team (SAPV) are certainly informed, so they can provide appropriate support there; and through these discussions, which are admittedly somewhat time-consuming, one can then hopefully structure the situation well in accordance with the patient’s wishes.
Görtz: Well, my approach wouldn’t differentiate between them in any way; that’s how I’ve always done it in the past. Not just with abdominal aortic aneurysms, but also with end-stage peripheral arterial disease patients. The crucial thing is the discussion with the relatives, the patient and the GP.
Adili: When does the situation shift from curative to palliative for you? Where is the inflection point?
Steinbauer: And there it is; in vascular medicine, we really do have two almost diametrically opposed situations. One is, for example, as just mentioned with the aneurysm: in the event of a rupture, we suddenly go from a normal curative situation to a potentially palliative one, and that happens within a few minutes. Naturally, this is much more difficult to communicate and also requires very urgent intervention.
Conversely, however, we then have situations, for example, with patients with chronic wounds, with severe internal medical limitations – PAD patients – where we have a slow, creeping change, where it makes sense to move away from the curative setting and make decisions that are more symptom-oriented and patient-centred approach, and this shift in perspective – which is then more the patient’s perspective that we should be adopting – signifies a gradual transition from curative to palliative medicine.
And we must deal with this situation in exactly the same way and must also learn to explain it to patients and their relatives, just as we would in the first situation where we have an emergency.
Görtz: Well, I see palliative medicine as a whole as being rather under-represented in scientific discourse and within vascular medicine societies. Recently, or over the last few years, I have increasingly found that we have decided to manage patients palliatively. We are not yet accustomed to dealing with this at the moment; there is certainly still a need for us all to learn. Also, the fact that we are asking ourselves this question at all.
But there is also a problem in the public eye. In the public eye, palliative medicine is often equated solely with cancer. However, the fact that cardiovascular diseases sometimes have mortality rates that far exceed those of cancer is largely unknown, and I believe that we, as a professional society, could also play an educational role here. So ultimately, we need to talk about this, and the aim of palliative medicine is, after all, to give more life to the remaining months rather than adding further months to life – in other words, to improve quality of life in the final months and enable patients to lead a largely self-determined life.
Adili: So what does that mean in detail then? What is it that matters when it comes to palliative care in vascular medicine, Hartmut?
Görtz: Well, of course, it’s crucial to prioritise pain management. But one must also ensure that quality of life is maintained to some extent. Under certain circumstances, this may even involve a minor reintervention; if it’s possible or foreseeable that an endovascular procedure can resolve the problem—the CIDI—then that is sometimes justified. But I believe that freedom from pain, clean dressings, and the technique of applying pain-free dressings are key points. But Markus, you’ve also looked into this in depth.
Steinbauer: Ultimately, it all starts with the wording. Yes, that has always been the problem: that often neither patients nor their relatives wanted palliative care as a goal at all. Here, I think it’s also possible to say that we’re providing symptom-oriented care, and from precisely this perspective, it’s important – as you’ve already said – to define the goals: Is the aim to stabilise a wound in order to avoid an amputation? Is the aim to make care easier through appropriate pain management or wound care? And at the same time: what else can be done to improve quality of life in that setting, whether at home or in hospital? And there, I believe, lies our main focus: building up expertise within our outpatient clinics and wards through staff in vascular surgery with palliative care skills, and cooperating with hospital structures such as palliative care wards, as well as outpatient services like SAPV units or hospices. And I believe there is still a great need for action in this area within vascular medicine and vascular surgery. We certainly have some expertise here and there, but we make too little use of it and we don’t think far enough ahead, both in the inpatient and outpatient sectors.
Adili: Yes, you both know that training and continuing professional development is a real passion of mine: Markus, how do you teach this – your trainee doctors, how do they learn it? How do they recognise that boundary between curative and palliative care?
Steinbauer: What has helped us most was the further training of a member of staff who wanted to do this and who, so to speak, then regularly led the discussions on the ward. And bringing this expertise to bear led to two other members of staff doing the same. And this expertise, combined with regular discussion during meetings regarding indications, during ward rounds, but also during discussions of complications, ultimately helps us move forward.
And a third aspect is ultimately writing publications, undertaking book projects and having outstanding colleagues on hand who are pioneers in this field and whom you can always ask for advice.
Adili: Let’s stick with heel necrosis for a moment – that is, after all, a serious condition. Let’s imagine a very elderly patient, say 92 years old, with pain at rest: what does palliative care entail here? Is the question: revascularisation – yes or no? Amputation – yes or no? Forgoing antibiotic therapy in a palliative care setting? What is your approach here, and what are your thoughts on this, Hartmut?
Görtz: Well, first and foremost, after a proper assessment, I would discuss the individual treatment goal with the patient, and if possible – or ideally, of course – with their relatives as well. It naturally depends on the patient’s condition. If, for example, this patient is severely cognitively impaired following three strokes, as you said, and is bedridden, then one really must consider whether a palliative approach isn’t the right course of action here. That means ensuring she is free from pain, but also ensuring, through discussions with the family, that antibiotics are not administered in the event of sepsis if the dry necrosis eventually becomes moist.
However, if the patient is still participating in life, if her cognition is, let’s say, good, if she takes pleasure in things and is therefore really, really living in that sense, then one should certainly consider a primary amputation. Because if she is no longer able to walk for other reasons, that might well be the easier option. So I also believe that primary amputation has a place in treatment, particularly in older people.
Steinbauer: I can only wholeheartedly agree with Hartmut. However, there are a few simple aids that are very important: if, for example, we have pressure ulcers on the heel due to contractures, and the risk to the patient from any surgical intervention is too high, then it certainly makes sense to try appropriate pressure-relieving shoes that prevent this pressure – these are now plastic shoes – I won’t mention any names, for competitive reasons, so to speak – which certainly help preserve the limb, alleviate symptoms and facilitate better care. And such simple aids alone must be taken into account and can often be more beneficial than an amputation or surgical intervention.
Adili: In the discourse, particularly at conferences, the showcase of revascularisation procedures is taking up an ever-greater space, and naturally this includes minimally invasive procedures in particular. That is, those where you don’t have to make an incision, can avoid a bypass, and achieve revascularisation through a puncture, balloon dilatation, a stent or ablation procedures – it is minimally invasive.
Are these procedures really as minimally invasive as they appear? And do you feel that perhaps this decision to forgo that step has led to the threshold for treatment actually being lowered, even when one might not be as convinced of the long-term results, of the outcome, as you have just so clearly outlined?
Görtz: Firstly, it must be said that, yes, these procedures are considered less invasive. That may well be true for a large group of patients. However, there is now very good data, including registry studies involving tens of thousands of patients, which show that the endovascular procedure is no less burdensome for the patient than open surgery. So the complication rates and outcomes are comparable between endovascular and open procedures; there’s no need to harbour false hopes. As for your second question, I must say: I do see a certain tension in the area we’re operating in. And the psychological barrier is, of course, significantly lower with endovascular procedures than the barrier to performing a procedure via a puncture. The reluctance to perform a supposedly simple, minimally invasive procedure is lower than when, for example, one has to treat a patient with an incision and requires a bypass operation or retroperitoneal access to carry out the procedure. And as I said, we find ourselves in a dilemma: there are, of course, incentives within our healthcare system to perform procedures that lower the threshold for indications. This is naturally linked to the fact that services are paid for, and for hospital managers, good surgeons are those who perform a high volume of procedures, and that creates perverse incentives.
Steinbauer: And unfortunately, a comparison with international partners shows us that Germany performs too many procedures in this regard, and we really must not shy away from questioning ourselves on this. I must sadly admit that we, too, currently have patients on the ward where we are ultimately facing complications arising from the indication itself and complications from the intervention. And that is something we really must give serious thought to.
I also believe that the older and sicker the patient is, the more the underlying condition determines the complication rate and the outcome, rather than the procedure itself. I believe that the intervention must then be viewed almost exactly like a surgical procedure, and that is also something we need to change in our mindsets. Patients’ vulnerability increases with the severity of the disease in old age, and so the indication and the aim of the treatment must be defined even more carefully. And this applies to a large extent, above all, to interventions.
Adili: So, if I may summarise that: good vascular medicine in older patients, or invasive vascular medicine, is less a question of feasibility and more a question of the quality of decision-making.
Markus, what would be your most important, non-routine action when treating very elderly patients with PAD, for example?
Görtz: Ultimately, it’s about identifying what limits the patient the most. Is their walking distance truly the limiting factor? Might the wound they have actually be stable, and are we perhaps not under as much pressure as we think?
And ultimately, it really is about engaging with the patient, and that is precisely where the geriatric assessment and evaluation of their environment are very important, in order to answer exactly these questions and not simply say, following a standard: ‘We’ll do either A, B or C.’
Adili: What would be your typical mistake in thinking, Hartmut, that you would warn every colleague about in relation to the treatment of elderly people with vascular diseases?
Görtz: That is probably the recommendation not to implement a guideline, but to view a guideline as a guideline that provides us with guidance in our decisions, but which is not a rule.
There are many examples: one example was what we’ve just discussed regarding endovascular reconstruction of aortic aneurysms. The guidelines state: 5.5 centimetres for men – in the case of very elderly patients, due to lower life expectancy and a higher complication rate, this threshold for surgery must naturally be higher.
Another good example is actually that of a bedridden patient who has had four strokes and is no longer participating in life. The question is: Do we continue to give him anticoagulants to prevent strokes? The guideline says yes, but reality says: No, I won’t do that.
Steinbauer: Perhaps I can add something here, not so much a typical fallacy but a thought-provoking idea: I occasionally offer advice to young colleagues who aren’t sure what makes the most sense by asking them: ‘What would you actually offer your grandmother and grandfather?’ – And suddenly you notice a certain shift in their decision-making.
Adili: Yes, that’s a good thought, one that actually always accompanies me in my daily work. I ask myself: would I offer this to your father or my mother in the same way as I would to this patient? I think that’s also very, very helpful.
Görtz: It would also be important to consider the question: what do older people actually want? An older person, as there are some excellent studies on this, is generally preoccupied with death – that is not their greatest fear. The greatest fear is actually the fear of being alone and needing care – and we must keep that in mind, and our decisions should also be guided by it.
Adili: Finally, I’d like to touch on a topic that I personally consider very important, namely interdisciplinarity in geriatric medicine. We’ve now started working with geriatricians to launch joint initiatives and provide support. My question to you: Do you work in a structured way with geriatricians? Do you believe that a geriatric assessment should be standard practice in vascular medicine? And do we perhaps actually need more palliative care infrastructure and logistics, both organisationally and in terms of facilities, than what we currently experience in everyday clinical practice? That was three points.
Steinbauer: On the subject of working in a structured way with geriatricians: We are fortunate to have this strong geriatric department, and emergency patients, for example, are screened in the A&E department using basic assessment tools. If an impairment is then identified, we also call in the geriatricians. And I believe that is certainly something that helps us move forward. Especially as we learn a great deal from it ourselves.
And regarding palliative medicine, as I’ve already said, what has benefited us most is, firstly, the contacts with our palliative care specialists, but also the integration of their expertise into our own clinic. Because then it’s always available on site, and ultimately these are opportunities for introducing such practices. But there are many ways to Rome, and I believe it’s best if we do it in collaboration with the other disciplines.
Görtz: I can only agree. During my time in clinical practice, which ended two years ago now, I maintained very close contact with the geriatricians. However, this essentially involved inpatient care via early complex geriatric treatment – a tool that is very helpful. For this, it is not necessary for the patient to be in a vascular surgery or geriatric ward; rather, they can be in either one. You simply have to care for these patients collaboratively and then subsequently have them in the geriatric rehabilitation unit.
I tried to introduce the preoperative assessment; it was a bit difficult at first, and then I simply ended my clinical career – but I consider it absolutely groundbreaking; given everything we know and have learnt about it, it is an absolute must. It just won’t be easy to implement.
Adili: I can only fully agree with that. So, to summarise: our task is not always maximum intervention; it is maximum quality of decision-making. It is indeed an appropriate goal, and perhaps the maturity of our discipline as vascular specialists is precisely demonstrated here: namely, in advising people who, in their advanced years, find themselves in difficult circumstances, in the way we would wish to do so, as we do with our own relatives – namely with expertise, but also with ethics and empathy.
Yes, dear Markus, dear Hartmut, that has gone by very, very quickly. To me, this half-hour really did seem very short. I would like to thank you both very much for your input. I hope you enjoyed it as much as I did. One final message you’d like to share with our listeners: Geriatric medicine, Markus.
Steinbauer: Geriatric medicine is actually our main focus, and we may need to shift our perspective somewhat in this regard, even though the excellence of our vascular surgery work, so to speak, remains absolutely essential.
Görtz: So, for me, good vascular surgery or vascular medicine in old age means: careful evaluation, not based on what is technically feasible, but on doing what makes medical sense – and that is maintaining quality of life, whilst minimising the risk of losing quality of life as a result of the treatment.
Adili: Wonderful. Thank you very much to both of you.
To you too, dear listeners, thank you very much for joining us again. If you have any questions or would like to share your feedback with us, please feel free to write to us at podcasts@medizinkommunikation.org. If you’re listening to us on Spotify, you can also leave us a review.
I’m already looking forward to the next episode of ‘Gefäße im Fokus’ and wish you all the best. Stay curious and, above all, stay healthy.
