Advocates in vascular controversies

The cardiovascular surgeon may find bibliographic support for his or her particular therapeutic bias for almost any controversial clinical problem. Such management dilemmas are not unique to vascular surgery in particular or surgery in general but reflect much of the field of medicine. Therapeutic controversies usually represent our ignorance of the natural history of disease or the deficiencies in our knowledge of the efficacy of medical or surgical therapy. While prospective epidemiologic studies or randomized blind clinical trials should be the optimal basis for our therapeutic decisions, how much of medical practice can lay claim to such a foundation? This panel debate represents a programmatic attempt to accomplish what each of us should, but often fails to, do in reaching a clinical therapeutic decision in the face of controversial alternatives: namely, objectively search one's experience and the available literature, pro and con. This approach proved very popular to those attending the meeting of the Southern Association for Vascular Surgery. The audience was greeted with the fruits of labor of the panelists who had taken their charge seriously. As advocates of their particular position in the therapeutic arguments, each panelist had carefully reviewed the pertinent literature, much of which is subject to the deficiencies and bias that are reflected in our clinical approach to these problems. Indeed, some of the advocates used the same literature references to support their opposing sides of the argument. Nevertheless, the eloquence and intensity of each presentation heightened the interest and understanding of the audience to these controversies. The annotated bibliography left a tangible document of the effort that had been expended in this debate. One hopes that out of our increased recognition of the fallibility of some of our therapeutic approaches to vascular controversies will come future efforts to base our clinical decisions on the results of epidemiologic studies or properly designed clinical trials.