Integrated Care Systems and the Aortovascular Hub

Aortovascular disease, medicine, and surgery are relatively new terms that have appeared in the literature and in the designations and names of individuals, symposia, and institutions over the past 5 years, predominantly in the United Kingdom where cardiac surgery and vascular surgery are separate specialties and vascular medicine is not commonplace. We have recently attempted to define the term aortovascular medicine[1] as a coordinated multispecialty approach to a unique subgroup of patients with vascular disease. The general approach represents an example of an integrated care system (ICS) which forms part of the NHS (National Health Service) Long Term Plan with a multidisciplinary, multiagency approach to lifelong care of patients in local communities (https://www.kingsfund.org.uk/publications/integrated-care-systems-explained). This “clinical concept” article will attempt to explore the multidisciplinary networks that define this approach and explain the novel concept of the Aortovascular Hub as an ICS ([Fig. 1]). While not exclusively the case, much of the pathology addressed by aortovascular medicine and surgery relates to thoracic arterial disease and in particular syndromic phenotypes such as Marfan syndrome, Ehlers–Danlos syndrome, Loeys–Dietz syndrome, Turner syndrome, bicuspid aortic valve syndrome, and unspecified familial and nonfamilial gene-based processes. There is increasing recognition that patients with developmental anomalies, particularly those with dysplastic aortic arch and aneurysmal epiaortic vessels including aortic coarctation, are included in this group. The term “aortovascular” was first used to include the continuum of peripheral “nonaortic,” vascular manifestations of aortopathy, and this still remains the essence of aortovascular disease, medicine, and surgery. These pathologies are somewhat distinct from acquired degenerative arterial aneurysms and occlusive disease that accompany abdominal aortic pathology, peripheral carotid, and iliofemoral disease—the core practice of vascular surgeons. While not excluding degenerative disease, the nuances of the thoracic aortopathies and the requirement for broad multidisciplinary involvement in patient investigation, diagnosis and management, and broader social integration are the focus that in turn define aortovascular medicine. Operations on the thoracic aorta involving the aortic root and total arch are traditionally the realm of cardiac surgeons, and those involving aortic endovascular approaches are traditionally the realm of vascular surgeons. However, aortovascular surgery blurs some of these boundaries and partly describes collaborative, integrated, and holistic working on open approaches to the chest and neck as well as hybrid open/endovascular approaches. Such an integrated approach follows developments in other disease areas for a more holistic approach to improving patient care pathways, for example, in patients with atrial fibrillation.[2] Such integrated care approaches have been associated with a significant reduction in adverse outcomes.[3] [4] Aortovascular medicine and surgery in relation to vascular health of the population therefore requires input from a broad range of specialists and institutions throughout a patient's life as well as integration with allied health care providers. This represents essence of the “Aortovascular Hub” concept.