Dr. Lee Kirksey is a vascular surgeon at Cleveland Clinic’s Heart, Vascular & Thoracic Institute, where he serves as Vice Chair of the Department of Vascular Surgery. Board-certified in vascular surgery and a registered vascular technologist, he specializes in complex vascular procedures, including limb salvage, carotid artery interventions, and aortic surgery. A native of Ohio, Dr. Kirksey trained at The Ohio State University and the University of Pennsylvania before joining Cleveland Clinic in 2011. He has performed over 10,000 vascular procedures and publishes extensively on vascular surgery and health disparities.

Thinking about the fellows you train — whether currently or over the past few years — is there a topic or focus area that you think deserves more attention among vascular fellows today?

Absolutely. That’s a great question because, over time, we see a cycle in our training and practice. In medicine, and especially in vascular surgery, there is a clear loop between how we are trained, the care patients seek, and the treatments we provide.

When I think about my trajectory, I trained during the introduction of endovascular aortic devices — the Talent endograft with Dr. Michael L. Marin and Dr. Bruce Brener — and later saw FDA approval of the predicate endovascular aneurysm repair device AneuRx. I was part of that era of transition, where we had strong open skills but were also learning endovascular techniques. As my practice evolved, like many others, I shifted to a balance of 50-60% endovascular and 40-50% open procedures. Now, after 13 years at Cleveland Clinic, much of my work involves revisions — hybrid cases combining endovascular and open techniques.

The open skill set I developed early in my career has been really valuable to me. That’s why, as someone involved in training the next generation, I emphasize the importance of a broad skill set.

I believe our competitive advantage, our secret sauce as vascular surgeons — while we collaborate closely with cardiology and interventional colleagues — is our ability to determine the best therapy for each patient. The right treatment, for the right patient, at the right time. A broad armamentarium allows us to provide the most value to our practice partners, consultants, and healthcare systems.

That is my key message to anyone in this field, be they surgeons or proceduralists: develop a broad skill set. When you complete your training, you should be prepared to practice anywhere in the country, recognizing that vascular disease varies by region in both phenotype and morphology. If you have a broad skill set, you'll be able to do that.

Given your many publications in peer-reviewed journals and beyond, how would you guide early-career physicians who want to get more involved in clinical research? 

The caliber of emerging medical professionals in vascular surgery, cardiology, and cardiac surgery never ceases to amaze my colleagues and me. When interviewing these candidates, we often find ourselves thinking, Oh my gosh, if I were coming out now, I don't know how well I would have fared. It’s like watching athletes and realizing how much better and more prepared each new generation is. Their performance and skill levels are so much better. They are very prepared.

A big part of that is how early they get involved in research. One of the biggest barriers, in my mind, is access — knowing how to reach out to someone. I always encourage students to be fearless when it comes to reaching out to mentors. Sometimes, everyone is competing for access to someone who's extremely well-published and well-known, but just approaching someone about an interesting case can lead to publishing a case report or a small series. You learn so much from reading, preparing, and doing the hard work to gain expertise in an area.

I tell my students that once they've written a review paper, they become a mini-expert in that field. They’ve taken a deep dive, and they’ll never forget that body of knowledge. That’s my first recommendation: be fearless. Put yourself out there, ask someone senior — whether it's a resident or a staff member — if you can publish something with them. Take their suggestions, work hard, and be disciplined.

The second thing is what one of my former partners at Cleveland Clinic called the "finishing gene". Entrepreneurs also understand this — many of us have ambitious ideas, but we have to see them through to completion. No matter how big or small, we have to develop the discipline to finish it. Research involves more than just having a great question. There’s the process of collecting data, writing the paper, revising through editorial reviews, and finally, getting it published. That last step — the persistence to push it across the finish line — is crucial.

Even now, there’s nothing more rewarding than receiving an email confirming that your academic work has been accepted for publication. That feeling never gets old, and I see that excitement even in colleagues who have been publishing for years.

When treating calcified plaque — acknowledging patient variability — if you're approaching it from an endovascular perspective, do you have a go-to algorithm or a default way to treat it?

I’ve thought long and hard about how to make this a nuanced answer, but the truth is, I think intravascular lithotripsy (IVL) is a generational therapy — a treatment that is truly changing the field. There’s nothing we vascular specialists lament more than calcified blood vessels, whether open or endovascular. I tell my trainees all the time that this is our Achilles’ heel. It makes open operations more difficult and sometimes less durable. And with our previous endovascular armamentarium, it created significant barriers to achieving optimal outcomes.

My threshold for treating calcium isn’t very nuanced. Very early on, I turn to IVL. For full disclosure, I’m not a big atherectomy user. If there had been a therapy that preceded IVL in my practice, it probably would have been atherectomy. But in this day and age, I default to IVL. If there’s been a shift in my algorithm, it’s in using IVL more for in-stent restenosis as well.

We’ve published a couple of cases on this. Last year, we reported on patients in my practice with failed endovascular interventions using covered stents for aortoiliac occlusive disease. These cases involved under-expanded stents due to extrinsic calcium compression, and they responded remarkably well to IVL. The secondary results were on par with primary treatment using IVL inside a covered stent. From the aortoiliac level down to the tibial vessels, I don’t think there’s anything comparable right now. That’s not just a pandering answer — I truly think IVL is a game-changer. The increase in the adoption of IVL took place over a short period of time, which shows how effective people find this therapy to be.

In your career — whether early on or now with the fellows you train — are there business-related healthcare concepts that you either wish you had known about 10-15 years ago or would like fellows to have a better understanding of today?

I've been very involved with value-based care since arriving at Cleveland Clinic because our compensation and care delivery model are uniquely set up to excel in this space. I have some thoughts on what needs to evolve in how we train surgeons and vascular proceduralists.

First, historically, graduate medical education programs have done a poor job of preparing physicians in financial awareness — billing, documentation, reimbursement practices, and overall healthcare financial stewardship. 

Plastic surgery, for example, has done a good job in this area. Many plastic surgeons enter private practice, which is predominantly a fee-for-service model and less insurance based. Because of that, their training programs require them to develop proficiency in billing, coding, and documentation. They learn how to describe procedures and how to bill properly because it directly impacts their livelihood.

In contrast, we don’t do a great job of that. No one can point to a granular-level requirement in GME curricula for training on billing and documentation. As a result, physicians enter practice, and the responsibility of teaching these skills falls on their practice. If they join a non-academic practice that needs to keep the lights on and manage finances, they often go through a year or two of intense indoctrination — learning what’s necessary to be a sustainable organization. We're improving, but there's still much work to do.

The second issue is value-based care. If we want to build sustainable departments, hospitals, and healthcare systems, we have to be good stewards of our resources. Physicians should understand device costs, value propositions, and clinical quality outcomes. We need to know how to achieve the best outcomes for our patients in the most economically responsible way.

At Cleveland Clinic, we’ve done a good job integrating fiscal responsibility into discussions. For instance, in a limb salvage case, we ask: What devices do we use? What are the alternatives? How did we escalate care? How do we achieve the best outcome cost-effectively without compromising patient care? These are the subjects we need to focus on to prepare the next generation of physicians.