Book Review

Trials and Tribulations of Vascular Surgery: Evidence-based vascular surgery

N Engl J Med 1997; 336:1194April 17, 1997

Article

Trials and Tribulations of Vascular Surgery: Evidence-based vascular surgery
Edited by R.M. Greenhalgh and F.G.R. Fowkes. 434 pp., illustrated. Philadelphia, W.B. Saunders, 1996. $155. ISBN: 0-7020-2090-7

Uncertainty dogs our efforts to practice scientifically sound medicine in any field, and vascular surgery is no exception. How refreshing it is that two thoughtful and well-known scholars have been willing not only to admit this fact in print but also to pilot an effort to give us firmer ground on which to work.

The authors of this book were instructed to examine carefully, summarize, and comment on the evidence available to answer questions about the care of patients with vascular diseases; to make the firmest possible recommendations for management; and to reflect on areas in which further information would be valuable. The “trials” in the book's title are both randomized and nonrandomized, reviewed with attention to their potential weaknesses, and the “tribulations” are those of practitioners striving to make sound clinical decisions on the basis of imperfect data.

The chapter titles reflect both the editors' hope for open-minded discussions and the potential clinical importance of the areas addressed — for example, “Does Use of Beta-Blockers Have Any Impact on the Growth of Aortic Aneurysms?” “When Should We Operate and When Should We Leave Popliteal Aneurysm?” and “Is Primary Amputation Ever First Choice?” Some of the chapters summarize and reflect on the trials that pertain to the questions they set out to answer, but most do not. Where no such trials have been performed, one would hope for a rigorous analysis of the available evidence to inform practice; instead, an unstructured review of the literature, supplemented by expert opinion, is offered. References to textbook chapters sometimes form the core support for the management recommendations made in these chapters.

A structured review of the literature is tedious and time consuming to perform. Systematically extracting data, assigning a weight to the evidence, applying statistical expertise appropriately, and delving into the details of study design in order to learn from differences in results among studies are exacting tasks. However, if readers are not informed in detail about how an analysis of a confusing and voluminous literature was performed, they cannot make an informed judgment about whether that analysis applies to a given clinical situation or whether they agree with the conclusions reached by the analyst. A second edition of Trials and Tribulations of Vascular Surgery, in which the chapter authors adhered to the standards of evidence requested by the editors, would be very welcome indeed.

Martha D. McDaniel, M.D.
Veterans Affairs Medical Center, White River Junction, VT 05009