PII: S0741-5214(95)70054-4 O R I G I N A L ARTICLES F r o m the Eastern Vascular Society From the vineyard-Reflections and perspectives D o m i n i c A. D e L a u r e n t i s , M D , Philadelphia, Pa. A farmer, b e i n g at death's d o o r , and desiring t o i m p a r t t o his s o n s a secret o f m u c h m o m e n t , called t h e m r o u n d h i m and said, "My s o n s , I a m s h o r t l y a b o u t t o die. I w o u l d have y o u k n o w , t h e r e f o r e , that in m y vineyard there lies a h i d d e n treasure. D i g , and y o u w i l l find it." As s o o n as their father w a s dead, the s o n s t o o k spade and f o r k and t u r n e d u p t h e s o i l o f the vineyard o v e r and o v e r again, in their search for the treasure w h i c h t h e y s u p p o s e d t o lie b u r i e d there. T h e y f o u n d n o n e , h o w e v e r ; b u t the vines, after s o t h o r o u g h a d i g g i n g , p r o d u c e d a c r o p such as had never before b e e n seen. - A e s o p 1 I d o n ' t k n o w the purpose o f a Presidential Address. T o make mattcrs worsc, I have always been wary o f reports in which the purpose is n o t clearly stated. I t appears that their function is to deliver a messagc, make a statement, communicate facts, or even serve notice. The subjects o f these addresses are quite disparate, and it is often possible to detect some personal blas or conviction o f the author at that m o m e n t in his or her career. It is in this light that I relate these personal reflections. I t is appropriate at this point to recite an early 19th century prayer uttered by t o u g h Scots-Irish pioneers w h e n they departed for the wild and primitive American frontier ofMissouri. " L o r d , grant that I m a y always be right, for t h o u knowest I am hard to turn. ''2 " C H A N C E F A V O R S T H E P R E P A R E D M I N D " ( L O U I S P A S T E U R ) Sorne o f y o u will interpret m y following remarks as war stories, b u t there are lessons t o be learned f r o m our surgical heritage. I am lucky to have had a From the Pennsylvania Hospital, University of Pennsylvania, School of Medicine, Philadelphia. Supported by a grant from the John F. Connelly Foundation. Presented at the Ninth Annual Meeting of the Eastern Vascular Society, Buffalo, N.Y., May 4-7, 1995. Reprint requests: Dominic A. DeLaurentis, MD, 700 Spruce St., Suite 101, Philadelphia, PA 19106. J VASC SURG 1995;22:643-8. Copyright © 1995 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North Ameri- can Chapter. 0741-5214/95/$3.00 + 0 24/6]66749 professional career that spanned the era o f m o d e r n vascular surgery. I am saddened w h e n I read vascular reports with references n o older t h a n 10 years. H i s t o r y is valuable. A o r t i c a n e u r y s m In 1952, D u B o s t et al. 3 first reported the resection o f an abdominal aortic aneurysm. I had the g o o d formne to meet Dr. D u B o s t and hear hirn describe this first operation. The procedure was done in a retroperitoneal fashion w i t h a homograft. A l t h o u g h he performed several t h o u s a n d subsequent opera- tions, he joked about the fact that it was the first and only time that he ever used the retroperitoneal approach! In those early years, elective aneurysm resection was carried o u t as i f it were a cancer. The 1950s represented the pinnacle o f radical surgical treatment. It was n o t at all unusual during m y residency (1953 to 1958) to perform forequarter and hindquarter amputation for malignancies, 90% gas- tric resections for benign peptic ulcer, and pneu- monectomies for lung cancer. D u r i n g the early years o f m y training, ruptured abdominal aneurysms were n o t repaired. The diagnosis was made by laparotomy to exclude hemorrhagic pancreatitis, perforated vis- cus, and mesenteric infarction. After operation the patient was given lots o f opiates and allowed to die. In m y estimation the greatest breakthrough in abdominal aortic aneurysm surgery occurred in 1966 w h e n Oscar Creech, M D , applied his historical knowledge and described the nonresectionai treat- 643 •OURNAL OF VASCULAR SURGERY 6 4 4 DeLaurentis December 1995 m e n t o f abdominal aortic aneurysm. + This key change in technique led to dramatic lessening o f b l o o d loss, operating time, and m o r b i d i t y and mortality rates. I t is a technique that w e all use n o w , b u t it was first reported b y R u d o l p h Matas, M D , Dr. Creech's mentor, in 1902. 4 T h e prepared m i n d o f Oscar Creech, M D , modified this concept b y i n d u - sion o f a synthetic graft. W h e r e are w e g o i n g in 19957 The endovascular technique for treatment o f abdominal aortic aneu- rysm is interesting, b u t as a Pennsylvania D u t c h m a n w o u l d say " W h y d o w e d o this hard?" Endovascular surgery is here t o stay, b u t for abdominal aortic aneurysm management, I w o u l d keep m y eye o n the people w h o are talking a b o u t the cause and the pathophysiologic condition o f aneurysms. I believe the ultimate solution for aneurysms will be a genetic and biochemical prophylaxis and treatment. C a r o t i d a r t e r y s u r g e r y T h a n k goodness vascular surgeons are persistent souls! W e never were convinced that the disease f o u n d in ulcerating, debris-laden, stenotic carotid artery lesions was safe for the d o w n s t r e a m brain. N o r could w e be persuaded that aspirin, dipyridamole (Persantine), o r ticlopidine c o u l d really take o n this tiger. I n 1970 Fields et al. 5 r e p o r t e d the first large prospective randomized carotid s t u d y for patients w i t h transient ischemic attacks. Friedmann reminds us that in that study, if the perioperative mortality and stroke rates were ignored (they were high), the surgical survivors s h o w e d a definite and significant advantage. 6 I t t o o k m o r e than 25 years and at least four o r five large prospective randomized studies to p r o v e that surgery is superior in patients with s y m p t o m a t i c and asymptomatic stenoses if w e keep the perioperative mortality and m o r b i d i t y rates low. Dr. Jesse T h o m p s o n et al.7 said this in 1966. Yes, w e d o toil and learn hard! These carotid artery studies d e m o n s t r a t e d that the margin o f error in vascular surgery is often extremely small. The future? Preven- tion and treatment are o u t goals, b u t o u r immediate chailenge is to identify w h i c h o f the patients with significant carotid artery stenoses will go o n to have a stroke (approximately 2 0 % ) and which will n o t (approximately 80%). The identification o f these t m k n o w n risk factors will save m u c h time, money, and suffering. L o w e r e x t r e m i t y i s c h e m i a In 1 9 4 9 Kunlin s first r e p o r t e d a reversed saphe- nous vein bypass technique. By the 1960s, there were sporadic reports o f bypasses to the tibial vessels, and in 1966, R. R o b e r t Tyson, M D , and 19 reported a series o f 12 patients in which tibial bypasses were carried o u t for threatened limb loss. In nine patients (75%) the inflow originated f r o m the superficial femoral (n = 7) o r the popliteal arteries (n = 2). T h e n w e wandered! S o m e M o n d a y m o r n i n g quar- terback decided that the only p r o p e r w a y to perform these bypasses was t o use inflow f r o m the c o m m o n femoral artery. I k n o w ischemic extremities were l o s t trying to fulfill this precept w i t h a reversed saphenous vein. I t g o t so b a d and w e w a n d e r e d so far, that Paul Friedmann, M D , and 11° even invented a n e w operation to o v e r c o m e the inadequate saphenous vein. W e called it the sequential composite bypass. I t was the last President o f this Society, Frank Veith, M D , w h o b r o u g h t us back to the proper path w h e n he again d e m o n s t r a t e d that an u n o b s t r u c t e d super- ficial femoral artery o r a popliteal artery is an adequate inflow vessel for a distal bypass. H F o r me, o n e o f the m o r e recent comforting aspects o f l o w e r extremity ischemia is the security and complete confidence that almost any chronically ischemic limb can be revascularized. O u r persistence has p r o d u c e d notable technical advances such as pedal bypasses, p r o d u c t i o n o f arteriovenous fistulas at distal anastomoses, patches, and the in situ technique. Endovascular techniques should enhance o u t ability to offer patients a less traumafic alternative to surgical revascularization, b u t I h o p e these results are measured against o u r weil d o c u m e n t e d historical patency and limb salvage rates. Incidentaily, in o u r rush t o embrace endovascular grafting for lower extremity ischemia, w h a t h a p p e n e d to the gold standard g r a f t - t h e saphenous vein? W h a t the f u m r e holds for patients w i t h end-stage ischemia o f the l o w e r extremities is n o t clear. It seems that w e have extended the frontiers o f b y p a s s i n g as far as possible; however, w h o knows? Are w e at a stage similar to that o f arteriectomy, which was being p e r f o r m e d b y R e n e Leriche w h e n his pupil, Kunlin, p e r f o r m e d the first bypass in 19497 D o e s a n e w and m o r e bountiful field üe ahead for the treatment o f this type o f ischemic disease? F E A R S - - P E R C E I V E D A N D R E A L T h r o u g h o u t m y professional career, I have wit- nessed challenges to the independence o f the physi- cian. In the late 1950s and 1960s, w e feared the medical school deans w h o w a n t e d physicians to be fiall-time employees o f the medical school. Flush with federal research money, m a n y deans did indeed accomplish this feat. H o w e v e r , once this source o f m o n e y was shut o f f (early 1970s), m a n y deans lost JOURNAL OF VASCULAR SURGERY Volume 22, Number 6 DeLaurentis 6 4 5 power. By then the open-ended Medicare program was in full swing, and money started to flow into hospitaks and physicians' practices at an unprece- dented rate. Major growth in hospital facilities commenced. In university and teaching hospitals, income derived from the clinical activity o f the full-time faculty helped support those institutions. We feared that wc w o u l d become hospital employees and that all monies for clinical, education, and research activities would be controlled by hospitals. Our enemy became the hospital and its ever burgeon- ing administrative staff. Technical industries re- sponded to the huge amounts o f capital in hospitals and a massive medical technical complex developed. These were the glory days o f procedure-oriented specialists. Finishing residents often commanded starting salaries in excess o f that o f their full-time mentors. Hospitals were in fat city, but medical costs soon became intolerable for large corporations and all businesses. In the early 1980s, as a consequence o f the escalating cost o f medical care, entrepreneurs, somc hospitals, and many corporations, aided by grants from the federal government, started to look at alternative care systems such as health maintenance organizations (HMOs). At this point in time, Medi- care costs were becoming a major federal budget expense., so price controls were imposed on medical providers. With reimbursement caps in place, doctors simply found a way to perform more procedures. You all know the rest o f this s t o ß . Today, hospitals no longer have the control, and our new fear is "managed care", better described as "managed cost." A major reason the Clinton Health Care Reform Bill failed was that the cost ofmedical care for employees had already started to decrease after implementation o f managed care policies. Many o f these managed systems are making great profits. Some physicians believe this to be unconscionable. However, could these middlemen make these profits (30 cents on each premium dollar) if fat or waste did not exist in the dellvery o f traditional medical care? I think not. I define fi~t or waste as money earmarked for direct patient care that never reaches the patient because o f hospital bureaucracy, poor physician management, unreasonable government mandates, and practice liability insurance. Some will challenge the last point, that is, the cost o f medical liability. They will condescendingly remind us that medical liability represents only 1% o f total health care costs. These experts, however, just don't get it. For most sur- geons, the cost o f medical liability insurance repre- sents 10% to 20% o f their income. Consequently, that 1% is responsible for higher indirect costs imposed on patients and third parties by physicians and hospitals. What will happen after managed care sldms all the cream and moves on to cover senior citizens? What will happen after the big health care buyouts and conglomerates occur? Incidentally, i hear no media outcry over the huge profits ($7 billion in 1994) made by these H M O s . It makes the decade o f greed (1980s) look like child's play. What will happen when managed care profits decrease because their reim- bursements are dependent on and pegged to govern- ment-capped Medicare and Medicaid schedules? I suspect that when the managed care systems can no longer squeeze any profit from this source, they will fall and will be bought out by, guess w h o - y e s , g o o d old Uncle Sam! We will then face the mother o f all fears! I predict that many hospitals by that time will go broke, and their bond issue defaults may make the savings and loan debacle resemble a picnic! O n the other hand, when m y gout is untier control, and there is a g o o d warm wind filling the sails, I dream that we will be savvy enough to pass a medical saving account bill, reestabllsh a private market for medical care by removing price controls, and that most bright young physicians, will have double degrees, not M D , PhD, but MD, MBA. W E H A V E A R R I V E D - L E T ' S N O T BE T H E LAST O N E S T O K N O W ! I vividly remember the joint annual meeting o f the Society for Vascular Surgery/International Soci- ety for Cardiovascular Surgery held in Carmel, Calif., in 1972, not because o f any particular scientific report, but because the pillars o f modern vascular surgery came out o f the closet and started to lobby for partition o f vascular surgery from general surgery. The concept they proposed was and remains that specialized training in this field should occur and should be recognized because it leads to superior care o f patients with vascular disease. The political battles were especially debilitating because we were all trained as general or thoracic surgeons. Separation was difficult, but it has occurred in spite o f sporadic skirmishes that still occur with the American Board o f Surgery (ABS) and the Residency Review Commit- tee ( R R C ) ) 2 By 1983, under the auspices o f the ABS, a new examination and Certification for Special Qualifications in General Vascular Surgery was instituted. That same year, programs offering special training in vascular surgery were reviewed by the R R C , and approval was granted to approximately 45 programs. In January 1984 the first edition o f our official journal was published. H o w could the JOURNAL OF VASCULAR SURGERY 6 4 6 DeLaurentis December 1995 IOURNAL OF VASCULAR SURGERY not be a stellar peri- odical with Drs. Michael E. DeBakey, Emerick Szilagyi, and Jesse E. Thompson as the founding editors, followed by Drs. Iarnes C. Stanley and Calvin B. Ernst? Although some traditional general sur- geons still blame vascular surgery for fragmentation, it is apparent, as other chunks o f general surgery break oft', that specialization should not be confused with fragmentation. Can anyone really criticize the concept o f specialization in burn and trauma centers, pediatric hospitals, or transplant centers? Specializa- tion will continue because it represents the desire o f patients, physicians, and scientists. This innate drive to do something bet-ter or find out that it doesn't have to be done at all will not subside, and, indeed, it should be encouraged. Although muted, I believe this concept has been accepted by the surgical profession. One only has to review the January 1995 American College of Surgeons Bulletin where "What's N e w in Surgery" lists 17 specialties; vascular surgery is friere, but general surgery is not. 13 The latter was replaced by specialties ofcritical care and metabolism, gastrointestinal and biliary surgery, surgical oncol- ogy, transplantation, and trauma and bums. As I dictate this address, I received notification from the staff liaison to the Advisory Council for Vascular Surgery that m y request to change m y specialty designation in the College's Yearbook to Surg(Vasc) was confirmed. The specialty o f general surgery has tried to define itself for some time. Meanwhile in real life its boundaries become smaller and less inclusive. It appears to me that all surgical specialties would benefit by a period o f training in basic surgery (3 to 4 years) followed by different spedalty pathways. Whether some vascular specialty pathways should be in a freestanding mode is not completely settled yet. I believe that freestanding specialty programs with dedicated teachers and facilities, a good supply o f patients, and a scholarly milieu will evenmally receive approval. Unless they have additional approved training, fumre general surgeons will not commence practice with an announcement that «their practice will include all aspects o f vascular surgery." Why is this? (1) Patients demand surgeons with additional train- ing and certification. (2) Training o f general surgeons in laparoscopy and minimal invasive techniques has diminished their time on vascular surgery rotations. In some institutions, especially those with a vascular fellowship, the senior general surgery resident rotat- ing through vascular surgery is often a fourth-year post-graduate student. (3) Hospitals, HMOs, and group practices demand special training and certifi- cation in vascular surgery. (4) The cost o f liability insurance is high. (5) Well-trained vascular surgeons are moving to rural and suburban areas. (6) Advances in vascular surgery such as endovascular techniques have a steep and long learning curve. The fumre for the well-trained vascular surgeon is excellent because (1) the specialty is blessed with good genes; (2) our specialty is based on a system rather than an organ (diversification); (3) the popu- lation is aging; (4) minimally invasive surgical techniques are being accepted, albeit with some hesitation; (5) the number o f vascular surgeons graduating from approved programs is relatively small; and (6) fewer general surgeons are trained adequately in all aspects ofvascular surgery (i.e. "Just teach me the technique!"). I f I were to name one drawback, it is that we are still hospital dependent, but even that can change in the future. O R G A N I Z E D V A S C U L A R S U R G E R Y As your President, I recently received a commu- nication from Robert Rutherford, MD, with regard to getting more "grass roots" vascular surgeons involved in "organized vascular surgery." It is m y perception that we are pretty well organized, but problems do exist with communication and with the lack o f unified clout in socioeconomic, professional, and political matters. The pyramidal structure oflocal vascular societies, regional vascular societies, and the national societies resembles a loose federation and makes the national impact ofvascular surgery diflicult to measure, market, or use efficiently. Our societies, joumal, certification process, training programs, and Association o f Program Directors are all in place. It is now time to pull it together, and bring all vascular surgeons into the fold. We are at the brink ofmaking this commitment. It will take the unselfish efforts and leadership o f the two national sodeties with the help o f all regional and local vascular societies to accom- plish this project. Communication should not be limited to vascular surgeons in national and regional societies, nor should we depend on a trickle down process o f information and education. Organized vascular surgery must include all vascular surgeons, beginning with those in training. The toughest part o f this assignment is to define a «vascular surgeon." The abuse o f using membership in vascular societies by poorly trained vascular surgeons as a mode o f pseudocertification can be curtalled, but at the same time, we must assure all well-trained vascular sur- geons that they are included in the system. Perhaps we should think in terms o f a national association o f vascular surgeons. IOURNAL OF VASCULAR SURGERY Volume 22, Number 6 DeLaurentis 6 4 7 It would be a mistake to dismantle our relation- ship with the ABS and the R R C . However, they must appreciate the fact that we have grown up and have left the fold. I f a sincere bilateral relationship o f respect is achieved, there will be no need to waste the time, money, and energy to develop a separate credentialing board and residency review committee. Time, however, is rtuming short on this issue. N U C L E A R V A S C U L A R FAMILIES Departmental structure in medical schools and hospitals shonid change to meer the professional, educational, research, and economic pressures o f the next century. Modern departments have existed for most o f this century, but with the explosion o f spe- cialization, they have contributed to duplication in teaching, patient care, and research. In addition, these departments waste money, soak up resources, and have led to debilitating political fights over mrfl. Think o f the efficiency, cost saving, enhanced teach- ing, superior clinical invesfigation, and quality pa- tient care that could be attained if we were part o f a multidisciplined vascular department made up ofvas- cular and cardiac surgeons, angiographers, cardiolo- gists, vascular internists, anesthesiologists, hematolo- gists, and so forth. This may sound qnite unortho- dox, but in our vascular group we are seriously considering recruitment o f a vascular internist and an angiographer as equal partners rather than additional vascular surgeons. This concept could lead to bun- dling o f services, cross-fertilization between disci- plines, and less expensive comprehensive care for pa- tients with vascular disorders. In 1995 the biggest smmbling block in our practice is the poor coordina- tion with and isolation from cardiology, anesthesiol- ogy, and angiography. The noninvasive laboratory should also be included in this concept. In our Sec- tion o f Vascular Surgery at Pennsylvania Hospital, we have been formnate to have our o w n approved, noninw.sive, vascular laboratory in our patient office area. All o f this may sound bizarre and impossible, but competiuon and economic forces could easily effect this restructuring. In such a multidisciplined departmental scenario, a surgeon may give up his position as captain o f the ship, hut what g o o d is being at the helm when the rudder stock is broken and our course is controlled by the winds and currents o f anesthesiology, angiogra- phy, cardiology, hospitals, and HMOs? Besides, have you hugged a traditional department chair lately and asked h o w much fun he is having! Namrally, this concept will be resisted to the utmost by the disciplines I mentioned, but just think h o w difficult it is in 1995 to coordinate and collaborate with your medical comrades and coworkers. In my mind, this arrangement will fulfill the logical goals o f consoli- dation o f clinical forces, rather than the concept o f grouping specialists into large single specialty syndi- cates because that will only lead to bigger, bloodier, and more expensive torf wars. A T H E R O S C L E R O S I S I was motivated to become a surgeon by a former mentor and Dean at Temple University, Robert M. Bucher, MD. His definition o f an ideal surgeon is an internist w h o understands pathophysiology, is inter- ested in cause and prevention, and, in addition, is able to cut! Over the past 40 years, surgeons have refined cutting techniques and have recognized the impor- tance o f perfection in performance o f operations. Indeed this technical emphasis has become almost an obsession. 14 However, shouldn't we participate in the quest for the solution to atherosclerosis? Except for a few excellent role models, the study o f atherosclero- sis, by most vascular surgeons, has been neglected and consists only o f prelirninary preparation for our board examinations. Yes, we know something about lipids, we have a hazy idea o f the hemodynamic factors that contribute to atherosclerosis, and we certainly understand the general risk factors (smok- ing, diabetes, hypertension, obesity, lack o f exercise, and hyperlipidemia). Let's be candid: vascular sur- gery would not exist if atherosclerosis, a generalized systemic metabolic disease, did not produce localized areas o f obstruction and degeneration. In these specific sites, organ, limb, and, indeed, life are at risk. Organized vascular surgery was wise when it estab- lished a f o m m for venous disease. It is my opinion that a similar program should be implemented with atherosclerosis. There a r e a host o f people worldng on this problem unknown to us and not in our societies. Indeed they consider our main thrust as mechanical treatment o f end-stage disease. We should know more about the basic pathophysiologic condition we are treating. We should participate in the study o f the cause, prevention, and treatment o f atherosclerosis. Most o f the reports on atherosclerosis are specialized and are foreign to us. However, that is a poor reason for not giving this problem more priority. We understand more about the end stages o f atherosclerosis than perhaps any group o f physicians. With gene therapy, new pharmaceuticals, space age imaging, and increased blood chemistry knowledge, we must look more seriously at this aspect o f our specialty. Finally, I want to thank you for the privilege o f JOURNAL OF VASCULAR SURGERY 6 4 8 DeLaurentis December 1995 serving as the ninth President o f our Society and for the opportunity to address you. As he grew old, my father had a favorite saying: "When one has teeth, he has no bread. When one has bread, he has no teeth." But in my case, I don't think it applies. I prefer the last stanza o f a poem by H e n r y Wadsworth Longfellow (Morituri Salutamus) written in his later years for the fiftieth anniversary o f the class o f 1825 in Bowdoin College: 1S "For age is opportunity no less than youth itself, though in another dress. And as the evening twilight rades away, the sky is filled with stars invisible by daß'. For me, being honored as your President is certainly a star that was invisible by day. R E F E R E N C E S 1. Aesop. The farmer and his sons. In: Bennett W, editor. The book of virtues. New York: Simon & Schuster, 1993:370. 2. McCoUough D. In: Truman. New York: Touchstone, 1992:16. 3. Dußost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta. Arch Surg 1952;64:405. 4. Creech O Jr. Endoaneurysmorrhaphy and treatment of aortic aneurysm. Ann Surg 1966;164:935-46. 5. Fields WS, Maslenikov V, Meyer IS, Hass WK, Remington RD, MacDonald M. Ioint study of extracranial arterial occlusion:V- progress report ofprognosis following surgery or nonsurgical treatment for transient cerebral ischemic attacks and cervical carotid artery lesions. JAMA 1970;211: 1993-2003. 6. Friedmann P, Garb MS, Berman J, Sullivan C, Celoria G, Rhee SW. Carotid endarterectomy-clinical results in a community-based teaching hospital. Stroke 1988;19:1323-7. 7. Thompson JE, Kartidiner NM, Austin DS, Wheeler CG, Patman RD. Carotid endarterectomy for cerebrovascular insufficiency: follow-up of 359 cases. Ann Surg 1966;165: 751-63. 8. Kunlin ~. Le traitement de l'arterite obliterite par la greife veinuse. Arch Mal Coeur !949;42:371. 9. Tyson RR, DeLaurentis DA. Femorotibial bypass. Circula- tion 1966;33(Supp 1):I-183-I-8. 10. DeLaurentis DA, Friedmann P. Arterial reconstruction about and below the knee. Am J Surg 1971;121:392-7. 11. Veith FR, Gupta SK, Samson RH, Flores SW, Janko G, Scher L. Superficial femoral and popliteal arteries as inflow sites for distal bypasses. Surgery 1981;90:980-90. 12. Porter IM. Editorial. J VAsc SURG 1993;18:100-1. 13. What's New in Surgery '95. Am Coll Surg Bull 1995;80:11- 85. 14. DeLaurentis DA. Choice and challenge in vascular surgery. Am J Surg 1989;158:84-6. 15. Longfellow HW. Morituri Salutamus. In: Untermeyer L, editor. The poems of Henry Wadsworth Longfellow. New York: The Heritage Press, 1943:434. Submitted May 11, 1995; accepted May 26, 1995. ERRATUM It has been brought to the Editors' attention that the report entitled "Luminal surface concentration of lipoprotein (LDL) and its effect on the wall uptake of cholesterol by canine carotid arteries" by Xiaoyan Deng, PhD, Yves Marois, MS, Thien How, PhD, Yahye Merhi, PhD, Martin King, PhD, and Robert Guidoin, PhD, J VASC SUR6 1995;21:135-45, should have included as a coauthor Dr. Takeshi Karino, Professor, Research Institute for Electronic Science, Hokkaido University, Sapporo, Japan.