Scott’s parabola (Figure 1) was conceived by British gynecologist J.W. Scott as a model to illustrate the cyclical “rise and fall of a surgical technique”: a procedure (or therapy) shows great promise at the outset, then becomes the standard treatment (standard of care [SOC]) after producing encouraging results, only to fall into disuse later as a result of negative outcome reports — and perhaps the availability of better new strategies. We all have seen this, haven’t we? While sharing only a distant resemblance to the abstract mathematical definition of a parabola,1 the chosen graphic representation does serve Scott’s ideas well by allowing the reader to gain a more clear and immediate understanding of the process at hand.
Having become acquainted with Scott’s publication2 only recently, it occurred to me that this model would apply rather well to present-day developments with new vascular technologies and therapies. We need not go far to find good examples: hot-tip laser angioplasty, atherectomy, various forms of myocardial revascularization, and many others. Non-vascular cases abound, of course, with estrogen hormonal therapy coming to mind as the prototypical case-in-point. To make it more complicated, some of these technologies (or techniques) have staged a comeback of sorts. Atherectomy emerges powerfully in this category, deserving perhaps of a follow-up editorial: When the Parabola Becomes a Circle! “Roller coaster ride” may be a more apt and descriptive term to reflect on the recurrent ups and downs of usage and popularity some well-known devices have gone through over the past several years. These things become even more difficult to define as technologies evolve, are reborn, continue to improve…and the like. Consider, for instance, the excimer laser, and then the turbolaser; cryoplasty, cutting and abrading balloons…and many others. Clearly, it would be nonsensical to put them all in the same bag — conceptually speaking.
This whole line of thinking revolves around the definition of the so-called SOC or standard treatment. It is the weakest link. Imprecise and incorrect usage of the term (in everyday practice and publications) has done much to diminish its significance. The SOC or “best practice,” has been defined as “the treatment that experts agree is appropriate, accepted, and widely used” or “a diagnostic or treatment process that a clinician should follow for a certain type of illness or clinical circumstance.” Importantly, there’s the legal definition of SOC: “It is the level at which the average prudent provider in a given community would practice; it is how similarly qualified practitioners would have managed the patient’s care under the same or similar circumstances.”
Having said that, please allow me to return to the reality of everyday practical medicine. The non-legal definition of SOC is far from agreed upon, or even understood. Literally, it depends on whom you ask — and when and where. And this is particularly pertinent today where the landscape includes involvement of multiple specialties providing vascular care. Still unconvinced? Try this: ask a vascular surgeon, an interventional radiologist, and an interventional cardiologist (who does peripheral intervention) what the SOC is for the treatment of occlusive disease in the superficial femoral artery, for below-knee arterial blockage or treatment of severe carotid stenosis…. You will likely and quickly find out that the “rock-solid SOC” is much “softer and adaptable” than one might have thought possible.
Lastly, let me point out the importance of differentiating tools (instruments) from therapy or strategies. For instance, there is no doubt stents are here to stay and are and will continue to be extremely useful instruments for many years to come. However, stent therapy is obviously controversial or possibly inappropriate in a number of applications or vascular territories. The same could be said for many instruments or tools, encompassing both new endovascular technologies and older more traditional surgical methodologies.
In the end, the take-home underlying message is that the rise-and-fall-scenario is a very common occurrence. In fact, it may well be an inescapable component (or result) of progress and innovation, a fact of life. But such understanding does not, in any way, diminish our collective duty and obligation to do the best we can for our patients. At any point in time, rigorous scrutiny of the evidence at hand should dictate the best choice of therapy for a given ailment or clinical problem. “Sexy new technologies” can be attractive and indeed offer the patient an appealing or even better treatment option, but this is not always the case….
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