Changing practice paradigms: negotiating your future.

There are many recent and ongoing changes in the practice of medicine from a business standpoint as well as in overall practice management. Economic and lifestyle desires have pushed many physicians to a decision point of whether or not to join a large multispecialty group or to sell their practice and become an employee of a hospital system. There are advantages and disadvantages to both options; however, deciding on the most appropriate path for each individual can be a daunting task. At our recent breakfast session at the vascular annual meeting in Chicago, Illinois, in June 2011, we brought to light these topics to try and help enlighten physicians on which option may be right for them. There is no single answer/option that will fit every practice, but discussion for various practice management designs are outlined and critiqued. This article cannot fully discuss each view in the allotted space, but it is designed to encourage thought and discussion among the vascular surgical community as a whole.

Metalloproteinase inhibition and the response to angioplasty and stenting in atherosclerotic primates.

Determinants of restenosis after angioplasty include constrictive remodeling and intimal hyperplasia. Both processes require extensive matrix turnover, so matrix metalloproteinases (MMPs) have become potential targets of antirestenosis therapies. We studied the effects of RO113-2908, a broad-spectrum MMP inhibitor (MMPI), on the response to iliac artery angioplasty and stenting in atherosclerotic cynomolgus monkeys. Lumen diameter (LD) was measured angiographically, and artery wall geometry was assessed after perfusion-fixation at 4 weeks. Angiogenesis was measured in subcutaneous polyvinyl alcohol disks. Treatment provided significant, systemic MMP inhibitory activity (97+/-2.2% inhibition of 25 nmol/L MMP-12 by serum) and inhibited angiogenesis (P=0.007). In contrast, loss of gain in LD (P=0.73) and constrictive remodeling (external elastic lamina area ratio [injured/uninjured x 100]: MMPI, 106.3+/-9.6% vs control, 119.9+/-7.2%; P=0.27) were not substantially improved 4 weeks after angioplasty. Treatment also failed to reduce intimal hyperplasia after angioplasty (intimal area [mm(2)]: 1.4+/-0.3 vs 1.6+/-0.2, P=0.65) or stenting (2.4+/-0.2 vs 2.8+/-0.2, P=0.12). In summary, inhibition of MMP activity reduced angiogenesis but failed to prevent constrictive remodeling or intimal hyperplasia after angioplasty and stenting in atherosclerotic primates. Additional research is needed to define the spectrum of matrix-degrading proteases critical in healing atherosclerotic arteries after angioplasty.