I’d seen vascular surgeons operate on ruptured aneurysms before as a medical school student in Buffalo. They worked, struggled, operated for a few hours, and still many patients died. But now it was 1979 and I was a first-year surgical resident on the vascular surgery service at Millard Fillmore Hospital in Buffalo, New York and I’d never seen anything like this: I am helping with a ruptured aneurysm.
It is Dr. Syde (Abe) Taheri and myself—no other help. In one fell swoop, he opens the abdomen of a patient from xiphoid to pubis. There is a lot of blood. He calmly reaches into the abdomen with his right hand and clamps down. The bleeding stops and the patient’s blood pressure improves, then he grabs an aortic clamp to replace his hand. All of this has taken less than two minutes. The operation continued. Amazing exposure was obtained, and I realized the meaning of what he would say “if I can see it, I can do it.” A tube graft is placed. His words, “Big bites, two ties” still echo in my memory. The entire case takes 52 minutes. The patient survived. My mentor had quietly arrived. I decided to follow him and learn everything I could.
At that time, there weren’t any vascular fellows—as a surgical resident you were it. There weren’t any interventional radiologists; we did all of our ascending and descending venograms. We did direct ambulatory venous pressure measurements by sticking #21 gauge needles into the dorsal veins in the foot, and we did a lot of axillary vein valve transplants.
Decades later, I still remember the first time he had me perform on a ruptured aneurysm. He had me slide my hand along his and feel where to be. He said, “Squeeze the aorta tightly.” He removed his hand and left mine. I felt a pulsation above my fingers and none below. There was no more bleeding. I was 26 years old. He had put the patient’s life literally in my hands, and I understood his intent. That is what a teacher does. That is what a mentor does. That is what a surgeon does.
The last time I saw Taheri was about 10 years ago at a VEITH meeting, and now I was about to interview him. I took a flight to Buffalo; it takes an hour from Newark. There is a lot that one can think about on a one-hour flight—and I did. I had already sent him some of the questions for my interview, but many others were coming to my mind.
I landed in Buffalo. It was mid-June, prime time to visit. The weather was perfect. I drive Canterbury Woods where Taheri lives—a retirement community. Michael Vasquez, who also trained with Taheri and who treats vein disease in Buffalo and is well-known for his work about VCSS and other quality of life indicators, meets me at the entrance. Walking down the hallway to meet Taheri, I notice that the place doesn’t smell like a nursing home. And there he is, exactly as I had imagined: gray suit, white shirt, no tie. It’s 1:15 p.m. on a Saturday afternoon. We sit, with his assistant Evan by his side, in a meeting area outside his room.
Some background: Syde “Abe” Taheri trained at the University of Pennsylvania and spent some time with DeBakey. Trained as a cardiothoracic surgeon. He is a surgeon/inventor. He is the inventor of the TALENT aortic endograft. He was one of the first to come up with the idea of an axillary vein valve transplant. He holds many patents. When asked what are you more proud of; the surgeon aspect or the inventor aspect of your career? His response is, “I don’t know what to say, I’m proud of both.” Wound up in Buffalo because someone called his chief in Pennsylvania and said they were looking for someone in Buffalo. As he says, “Buffalo has been good to me.”
The interview begins:
VM: When you were in training, vein issues were not a real part of a cardiovascular surgeon's training. What (or who) got you interested in vein disease?
ST: The general surgeon at the hospital impressed me with his meticulous job when doing a stripping. Also intriguing was his approach to the symptoms and complications of vein disease. Varicose veins presented a major issue in mental and physical well-being. I remember going to parties and women would hide their legs. The general surgeon, when doing a stripping one day, turned to me and said, “This (stripping) is not the answer. There is another problem, but I don't know what it is.” That got me thinking.
VM: Did this spark the idea of the vein valve transplant?
ST: Things come to my mind, usually two or so a week. Most I throw away, but this one I kept. So over a couple of years I was thinking of it. The concept was obvious: an incompetent valve will eventually lead to hypertension, ulceration, and tissue death. I realized if you prevent the hypertension, that you would prevent complications.
VM: Do you think that some of the patients we did a valve transplant on would probably benefit from iliac vein angioplasty and stent in 2016? By this, I mean they probably had obstruction as a major component and not insufficiency.
ST: The major problem to ulceration of the lower extremities is hypertension. If we could establish circulation towards normality using a venous valve, it is a lot better than hypertension.
VM: We still don’t have a good prosthetic valve option. You were working on this when I was in Buffalo. Why have we not accomplished this in 2016?
ST: Because we don’t have a dedicated venous research lab. Venous societies should get together and fund one. Maybe vein disease is a systemic disease, not just a disease of the veins. We need to explore this on the cellular and subcellular level.
VM: What is the next major advance we need to accomplish in the management of venous disease?
ST: Correcting abnormalities in collagen, fibroblasts, and elastic tissue may prove to be the way we should address the problem at a cellular and subcellular level. Inexplicable diseases, such as vein disease and others, may be the product of cellular mal-motion, not unlike an arrhythmia, which can cause metabolic disturbances. There is motion that we are missing. This should be investigated and corrected utilizing nanotechnology. Motion of the cells may not be seen by us now, but cellular mal-motion may start a cascade of events on a cellular level that then manifests as vein disease.
VM: You were the first of my three mentors. Without your influence, I probably wouldn’t have been interested in vein disease. The other 2 being Herb Dardik, another surgeon/inventor who developed the human umbilical vein graft, and Tom O’Donnell Jr., need I say more about Tom, a great friend for 25 years. Who were your mentors and what did they spark in you?
ST: I had no mentor like that, no venous mentor at least. The general surgeon was the leader in both general surgery and veins—I looked to him.
VM: Any advice for a young, bright vascular surgeon who wants to change the vein world?
ST: I would reiterate that basic changes of vein varicosities should be investigated at the cellular and subcellular level. Work never kills you. I did it, you can do it.
VM: I need to get a little personal. I have operated with many surgeons, but I have never worked with anyone who could get as rapid and complete exposure for a ruptured aneurysm as you. Skin to skin in less than an hour. Where did you learn this? Do you think this talent is not needed in 2016 with advanced endovascular techniques?
ST: I am glad you asked this question because, in a ruptured aneurysm, there is a window available through which the index finger and thumb can easily enter and encircle the aortic wall. This should not be associated with any instrument, you have to be able to feel it out. You need to feel the landmarks, the aortic wall and the lumbar spine, as your sight does not assist you. If you know where to go blindly, to use your judgement and feeling, that accounts for some of the rapidity.
As the interview ended, we shook hands. He thanked me for coming; I thanked him for his time. As he walked away with the help of his assistant and a nurse, I watched from behind. That goodbye was not enough. I followed him into his room. Put my hand on his shoulder. I needed him to know how important his influence was on my entire professional career back then—and now. I told him some people had suggested I interview him by phone or by email. I told him that it was important for me to do it in person. Something would be lost any other way but in person. I told him and sincerely thanked him. And then that 87-year-old man had a tear in his eye, and this 63-year-old had some too.
Words to live by:“Respect the elders, Embrace the new, Encourage the improbable and impractical without bias.”
We all need to know and appreciate how we travel along our professional path—how we got there. No one exists in a vacuum. In future issues, we will ask others to discuss their mentors. Contact me if you want to take up the challenge; it will enhance your life.
By Steve Elias, MD FACS FACPh
I don’t particularly care for baseball or baseball analogies, but this one may work. I do understand what the pseudo baseball intellectuals like about a game that is driven by statistics and subtle strategies, but an athletic contest without a time limit? Really? Who can plan anything when watching a baseball game? Paul Krugman, the economist writing in theNew York Times, described Donald Trump as being born on third base. Interesting image: a little baby residing on third base.
I was born in Brooklyn; Daniel Justus was born in Buchanan County, southwest Virginia, coal country, Appalachians. You get it? Justus was born in right field. Many of us can remember right field when we were incarcerated in Little League by our parents. It is below Purgatory; I am sure it fits into one of Dante’s Seven Circles of Hell. You never wanted to be banished to right field, where nothing ever happened except boredom or the desire to disappear into oblivion. Your parents would beg for forgiveness and wonder what sin they committed to have you sent to right field.
The worlds of Daniel Justus and Donald Trump surreptitiously synthesized on a flight back from my privileged annual trip to the LIVE Vascular Meeting in Greece. With not all that much to do at 38,000 feet except eat, drink and be merry like Robin Hood and his men in Sherwood Forest, I started to read the International New York Times and the Financial Times’ London weekend edition. Krugman’s scathing editorial about Donald Trump for the NY Times, and Edward Luce’s article about Daniel Justus for the Financial Times, melded in cataclysmic irony. The haves and the have-nots inexplicably joined for a moment in time in my mind.
As Krugman wrote, “Remember too, that Mr. Trump is a clear case of someone born on third base who imagines that he actually hit a triple.” Trump inherited a lot of money and influence from his successful father; Daniel Justus was born in Virginia coal country with little expectation of ever getting out of this economic and social right field—but he did.
With the help of supportive parents and his own will, he recently graduated from the University of Virginia. He speaks Spanish and Mandarin Chinese. He is an interpreter for the state of Virginia and works for a Chinese law firm in Shanghai. He has hit a home run, but he started in right field. Or worse. This is to be admired.
In the vein world, we all come from different positions, and most of us not from third base. As an eight year old, right field seemed to be my position. As a vein specialist, I am finally out of right field. Most of us are not in right field; most of us have not yet hit a home run. Most of us are somewhere between Daniel Justus and Donald Trump. In VEIN this month, we seek to get you closer to home, or at least third base.
This issue, Maria Urso gets us closer to home in her article, entitled “Effective Vascular Interventions,” by elucidating how we should be looking at data and reported outcomes. There are many ways to interpret data and results, and she gives us a sobering way of approaching this. Maria began her journey closer to third base than most of us.
If you think Mike Dalsing has seen it all, you are correct. He started in right field and worked his way to third base—and beyond. A person to be admired for his accomplishments and subtle self-confidence—attributes that would benefit many in the vein world if they took his lead and emulated his self-deprecation.
The Expert Venous Management course (EVM) held at Englewood Hospital every June has spawned many a vein specialist to elevate their care of the vein patient. The case presentation by Edgar Guzman, and the comments by Thom Rooke (one of the smartest people in the room), are very illustrative of the level of complexity covered during this meeting. Come next year. Another course that has recently been gaining some momentum is the HOT course, which fills the void for many neophyte vein care practitioners in the world of venous imaging. Read the article.
And now we arrive at the bottom of the 9th inning with two men on base and two outs. We need to highlight the mentors and pioneers in our world of veins. A number of articles in this issue of VEIN are written by, written about, or involve those who were there before most of us. The article entitled, “The Pledge,” involves the concept of stemming the tide of inappropriate or fringe vein care. This is written by Dan Monahan, Elna Masuda, and a giant among us who has seen it all and influenced most of us directly or indirectly: Bob Kistner. Nick Morrison is the first American to be the president of the UIP. Like Mike Dalsing, he started far away from third base, maybe even right field. But he has done it all and has given us a very complete, yet succinct article discussing the goals of the UIP and its global impact on venous disease.
Finally, the history of vein care would not be complete without the recognition and story of one of the pioneers in venous disease who has remained somewhat anonymous. For whatever reasons, Syde “Abe” Taheri is not a well-known name in our specialty. I hope my article, which begins our series about “Mentors Who Made Me,” sheds some light on the early developments in our world of veins.
Let’s now leave the world of veins, baseball, and coal country of Daniel Justus and explore the world of lipstick, specifically Ruby Woo lipstick. In the same issue of the Financial Times discussing Daniel Justus, there was an article about Ruby Woo lipstick. One never knows what will happen on an eight-hour flight.
Now, I don’t wear lipstick usually, but this article almost made me go out and buy some Ruby Woo. Apparently, Ruby Woo lipstick is distributed by MAC cosmetics. It is timeless. It could have been worn by Bette Davis in All About Eve, but she didn’t wear it. Why am I intrigued by Ruby Woo lipstick? Because obsession with perfection is what many vein specialists have. Anyone at any age can wear Ruby Woo, or as Kathleen Baird-Murray writes in her article for the Financial Times, “Ruby Woo transcends age.
It has a youthful vibe, but you can imagine an older woman carrying it off too.” Sounds like the management of vein disease: not just for the young, not just for the old, but for all. Get some Ruby Woo. Get yourself this issue of VEIN. Get to third base. Not necessarily in that order. Maybe read VEIN while standing on third base wearing Ruby Woo and speaking either Spanish or Mandarin Chinese. Have fun trying.