Dr. Bruce Perler, 2025 ISET Career Achievement Award Recipient:

Innovations, technology reshaping the future of endovascular practice

At the upcoming International Symposium on Endovascular Therapy (ISET), which takes place February 2-5, 2025, in Hollywood, Florida, Dr. Bruce Perler, a vascular surgeon at John Hopkins Medicine in Baltimore, Maryland, will be celebrated as the recipient of the 2025 ISET Career Achievement Award. We spoke with Dr. Perler to discuss his illustrious career in the field of vascular surgery and endovascular therapy. 

Can you reflect on your journey in the field of vascular surgery and endovascular therapy? What are some key milestones or turning points that have defined your career?

My journey, I suspect like many people, has been influenced not just by the technical and scientific advances over the years, but by the people I have had the blessing to be associated with. I completed my vascular surgery fellowship at the Massachusetts General Hospital (MGH) in 1982. In that era, vascular surgeons, with rare exceptions, exclusively preformed open vascular reconstructive procedures and catheter-based therapy was performed by interventional radiologists, and to a much lesser degree by some interventional cardiologists. That was certainly the situation at the MGH during my training, where there was a very collaborative relationship between the vascular surgery division and the interventional radiology division in managing our patients. The attending staff within the interventional radiology division at the MGH included a number of amazingly talented specialists from whom my patients benefited, and I learned so much. As a vascular surgery fellow at the MGH, one of the people I most closely worked with was an interventional radiology fellow, Dr. Arina Van Breda. Arina went to Alexandria, Virginia and developed an incredibly successful interventional radiology practice there, and one of her partners was Dr. Barry Katzen! Barry spent several years in Alexandria before moving to Miami and establishing the world-class Miami Cardiac and Vascular Institute. Arina hosted annual vascular educational symposia and often invited me to speak on the faculty, and this is where I met Barry Katzen for the first time and got to know him, and that relationship has persisted for roughly 40 years as we interacted professionally through many educational endeavors, including ISET.  

When I completed my vascular surgery fellowship at the MGH, I took my first academic appointment at Johns Hopkins where I have spent my entire career. Like the MGH, the vascular surgeons performed open surgery and the interventional radiologists performed almost all the catheter-based procedures at Johns Hopkins. My patients clearly benefitted from the expertise of interventional leaders at Hopkins like Dr. Robert White, with whom I also collaborated on scholarly activities. I’m very proud of the fact that throughout my time at Johns Hopkins, and in my interactions across specialty lines in general, I’ve always engaged in a collaborative relationship with my interventional colleagues and learned from them, to benefit our patients and which was borne of my time as a trainee in Boston. 

As my academic vascular surgical career progressed, I began to be invited to speak at vascular educational symposia around the country, and consistent with clinical practice, there was often a multidisciplinary faculty with vascular surgeons speaking about open surgical procedures and interventional radiology faculty members speaking about catheter-based therapy. It was at these meetings that I met and got to know some of the giants in the field of interventional radiology outside of my institution, like Drs. Tegtmeyer, Ring, Sos, McNamara, Wholey, Dake, Palmaz, and others. The first textbook I published, Vascular Intervention: A Clinical Approach, was co-edited with Dr. Gary Richter, formerly of the Miami Cardiac & Vascular Institute, and incorporated interventional and open surgical topics. 

As catheter-based therapy assumed an increasing role in the management of circulatory disease, the specialty of vascular surgery evolved to incorporate interventional procedures within the specialty and in our practices. So during my time as a faculty member at Johns Hopkins I spent 1 day per week for a year working with a colleague at a hospital in the University of Maryland health system training in endovascular therapy, and then began performing these procedures in my practice. There was one defining case during that era. In the early 1990s, an 84-year-old woman presented to our Emergency Room with a ruptured AAA. She was exceedingly frail, in atrial fibrillation with severe congestive heart failure, COPD, and hypertension. We had published an outcomes study demonstrating that in Maryland the operative mortality for all octogenarians undergoing repair of ruptured AAAs was 67%, and this patient’s comorbidity made it unlikely that she would survive surgery. But I partnered with Dr. Lawrence (Rusty) Hoffman of our interventional radiology group, and we performed an EVAR, she survived and lived an additional 6 years. This case sold me on the endovascular revolution. 

As this evolution occurred at Johns Hopkins during my tenure as Chief of Vascular Surgery, we began performing procedures that previously had been referred to and performed by our interventional radiologists, I’m very proud of the fact that we continued to maintain a collaborative and cooperative relationship across these specialty lines without turmoil or conflict as occurred in many other institutions. There is no doubt in my mind that my approach to leadership during this evolution was influenced by my early background and experiences, and specifically my interactions and relationships with those pioneering interventional radiologists.

In your experience, how have you seen the field of endovascular therapy evolve over the years? What do you consider to be the most significant advancements or innovations in this area?

We’ve come a long way since Charles Dotter, the father of Interventional Radiology, performed the first percutaneous angioplasty of infrainguinal arterial occlusive disease in the 1960s. There are several inflection points in this endovascular evolution.  

The development and evolution of endovascular aneurysm repair has been a monumental advance. Patients who might not have been well enough to undergo aortic aneurysm repair are now undergoing EVAR. And patients who would have been hospitalized for a week after an open aortic aneurysm repair and in a weakened state at home for 6 weeks or so thereafter are now being discharged within 24 hours of the endovascular repair, if not on the same day. And we are seeing that these endovascular repairs are durable. What has been particularly remarkable to me has been the rapid development of our capacity to now treat complex aortic pathology in an endovascular fashion, such as juxtarenal and suprarenal aortic aneurysms, and even now thoracoabdominal aortic aneurysms and aortic dissections with endovascular technology. This has transformed patient care and transformed the specialty of vascular surgery. On the cardiac side, TAVR is a comparable advance.

TCAR was an innovative advance in the treatment of carotid artery disease to avoid catheter manipulation across a diseased aortic arch, and has significantly altered the care of patients with carotid artery disease.

Patients with peripheral arterial occlusive disease are significantly benefitting today from the development of drug-coating of balloons and dramatic improvements in stent technology, including drug-coating of stents, and by the evolution of enhanced biologics in this regard. Further, great progress is being made in bioabsorbable stents and stent technology for small vessels such as tibial arteries.  

These endovascular interventions have benefitted from continued advances in imaging technology and innovative improvements in catheter design.
More patients suffer from venous disease and the development of percutaneous techniques such as radiofrequency ablation, laser ablation, and other percutaneous modalities are sparing patients the morbidity of saphenous vein surgical stripping.

At the symposium, various innovative techniques and technologies are being discussed. What are some emerging technologies or techniques do you find most promising for the future of endovascular therapy, and why? How might they change current practices? 

It’s almost cliché to say that AI will have a major role in the care of patients in this field as throughout all of medicine, but the early research in the vascular arena is very exciting. Contemporary research in AI is demonstrating the potential to predict clinical outcomes of specific procedures, allowing one to select the most appropriate procedure for a specific patient.  For example, I’ve learned of research using AI to analyze the aortas taken from individuals who have suffered a ruptured AAA, and based upon this tissue and AI interpretation the investigators believe they can predict which 3.5 cm. AAA is likely to rupture and therefore should be repaired, and which 8 cm. will not, and can be followed. 

There are many other areas of potential enhancement of endovascular practice. 3D printing may allow the production of stents and stent graft specific to an individual patient’s anatomy.  Robotics may allow more precise catheter placement. The continued development of bioabsorbable stents offers tremendous promise in reducing restenosis rates after treatment of arterial occlusive disease. Developments in nanotechnology may allow delivery of bioactive agents into disease territories.  Advances in imaging systems will benefit endovascular therapeutic interventions through improved intra-procedural decision-making. And new developments in wearable monitoring technology, perhaps using AI, may allow real time assessment of an individual patient’s vascular health and the performance of an endovascular intervention.

The symposium will highlight diverse case studies and patient outcomes, how do you approach incorporating findings from these studies into your own clinical practice? Are there particular examples where recent research has significantly influenced your treatment strategies or decision-making process?

We are generating medical information faster than at any time in our history.  I saw one estimate that in 2010 medical knowledge doubled every 3.5 years and in 2020 medical knowledge doubled every 73 days!  As a former Editor of the Journal of Vascular Surgery, I know that from the time a research article or clinical study is submitted to a peer-reviewed journal, it can be 6-8 months before that paper is reviewed, accepted, and published in hard copy. While electronic publishing has reduced to some degree the time from a paper’s acceptance to its publication, the timeline is still long. Nevertheless, I think there will need to be continued investment in electronic communication of clinical research and potential advances in clinical care. Among all the publications that cross our desks every month, I think the most valuable publications to read are clinical practice guidelines documents published by our specialty societies.     

Having said that, more importantly, while COVID profoundly changed educational activities with a reduction in in-person meetings and transition to virtual learning, and that paradigm shift to a significant degree has persisted to the present time, I firmly believe there is no substitute for in-person education, like ISET and other similar programs.  In-person educational meetings allow not only for the attendee to learn of the latest advances, but also provide an unparalleled opportunity to learn from the back and forth, give and take, pros and cons articulated by experts in the field who can authoritatively address emerging data and knowledge. It clearly has been very instrumental in my learning process.

One very important recent clinical study to be published was the BEST-CLI trial, an incredibly complex randomized clinical investigation.  I’ve attended several educational meetings where the findings of this landmark trial have been discussed and debated, and this discourse provides the kind of information the clinician needs to truly incorporate the findings into one’s practice in the management of critical limb ischemia.  

What do you believe are the current challenges or gaps in endovascular therapy, and how do you see these being addressed in the near future? Are there specific areas where you think more research or development is needed?

It is said that achieving the best clinical outcomes requires doing the right procedure on the right patient at the right time. In other words, patient and procedure selection are key in endovascular therapy as in open vascular interventions. At times one might observe technology in search of an indication. The first challenge, therefore, is selecting an endovascular treatment for a patient when it is the most appropriate option, and not trying to “push the envelope” of endovascular intervention when an open procedure might be best for that patient. Improved imaging technology, and very likely AI, will inform these judgements in terms of patient and procedure selection in the future. 

Increasing challenges will be faced within the health care system to require the delivery of not only clinically effective, but equally importantly, cost-effective care. Increasing emphasis should be placed on minimizing complications and enhancing long-term durability to avoid repeat interventions. The development of better stents, better drug availability for drug-coated balloons and stents, and biodegradable stents represent the potential to enhance patency of endovascular interventions and reduce the need for reintervention and ultimately to reduce the cost of care. Advances in our understanding of the basic biology of circulatory disease processes will allow development of preventive treatments for circulatory diseases and also the potential to prevent recurrent disease following intervention. In this regard, I believe there should be greater emphasis on the collection and reporting of more long-term outcomes. Any major shift in reimbursement models within our health care system, such as capitation, will potentially have a significant impact on endovascular interventional practice. 

Furthermore, recent studies have indicated a disparity in access to advanced endovascular care, especially among underprivileged populations. More equitable geographical distribution of endovascular specialists, more widespread use of telemedicine for patient evaluation, and other strategies will be necessary in the future. 

Looking ahead, what advice would you give to the next generation of vascular surgeons and endovascular specialists who aspire to make a significant impact in the field? What qualities or skills do you think are essential for success in this specialty?

First and foremost, in my opinion I think one must appreciate that we are truly privileged to be able to care for patients. I can think of no other profession where the results of the work we put in are so gratifying to us in terms of serving our fellow men, women, and children. Our approach should always be patient-centric. As in any field, one must have a passion for what one is doing. In this world you can't fake it. So, in my view, the successful endovascular specialist, or vascular surgeon, of the future must have a passion for the science and challenges of the discipline. One must have a compulsive approach to managing patients, including both excellent cognitive skills in diagnosing problems and formulating therapeutic strategies as well excellent technical ability in performing procedures whether they be endovascular or open surgical. This begins with achieving the best training one can possibly receive. One needs to be an excellent problem solver. One must bring to the operating table in the OR or to the cath lab a dedicated focus. One needs to be exceedingly compulsive in approaching each patient. One has to be technically talented but also cognitively astute. One has to have tremendous analytical skills to assess the problem, the potential options, and to plan procedures accordingly.

One needs to be continuously curious, constantly reading the literature, attending educational meetings, and being cognizant of the latest advances and innovations in the field to optimally benefit one's patients; ie, one must be a lifelong learner. One needs excellent interpersonal skills and should be an excellent communicator, utilizing those skills to inform the patient and learn from one’s colleagues.