Health & Disease Info
All You Wanted to Know About ... Endovascular Surgery

The field of vascular surgery is advancing very rapidly. As in all fields of medicine, we are trying to develop new and better ways of treating problems with as little challenge and inconvenience to the patient as possible. Traditional surgical approaches usually involved large or multiple incisions. Most incisions are painful and take six to eight weeks to heal completely. The pain, inconvenience (activity restrictions and time off work while the incisions heal), and total body stress as the patient recovers from surgery are the main targets of our endeavors. Endovascular surgery (ES) is our way of addressing these challenges. IT is a way of doing minimally invasive surgery (MIS) addressing a problem from the inside of the artery rather than violating the body to get to the entire artery in the standard approach.

Before going into specific techniques we want to make sure you understand that at this time only a few patients have anatomy which is appropriate for this type of MIS. Not everyone will be a candidate for an endovascular approach to their problems. Some patients will be able to be treated completely by endovascular means. Some will be able to have part of their problem treated this way while the rest is treated in standard ways. Unfortunately for many, their disease will be so advanced that our endovascular approaches will not have been developed sufficiently so that they will be candidates or the traditional open approaches only. It is this group that we are working hardest to reduce. As always, we will discuss all available options with you at the time of your consultation.

There are a few caveats and limitations which have to be address. At this time, with the exclusion of aneurysms, we are limited to treating only short segment disease when we use an endovascular approach. Many times we will find only a short segment of narrowed vessel. This can be treated well by these new techniques. Larger segments of disease respond less well and fro a shorter duration of relief before recurrence. There are some arterial segments, which respond better than others and some vessels have a higher ate of recurrent narrowing while other have a long duration of effectiveness. Finally, and most importantly, while we may intend to use an endovascular approach to a certain problem, there is always the chance of having to convert that to an open procedure if problems develop. That is why we plan to do many of these in the operating rooms, so that if we do run into a complication, we are prepared to take care of it.

All active treatment has to start by visualizing the blood vessel involved. We usually start out by performing a "duplex mapping" of the diseased vessels in our vascular laboratory right here in our office. If we discover a very localized blockage we may be able to recommend treatment based solely on that study. If longer or multiple segment disease is found, a standard arteriogram will allow us to see a "road map" of the diseased arteries.

Arteriography is the basic starting point of all endovascular procedures. Usually we do this ourselves as we start an endovascular procedure. It involves putting a needle into an artery (usually in the groin area) and then advancing a guide wire and catheter or sheath through that area so that dye can be injected and our road map obtained.

Once the needle has been placed and the guide wire and catheter advanced into position, the angiogram is performed and x-rays are taken. (Be aware that the words "angiogram" and "arteriogram" are used interchangeably.) If this demonstrates a limited area of disease, we may then decide to approach it endovascularly. Our options include balloon dilatation (percutaneous transluminal angioplasty or PTA" with or without placement of a metallic stent. Other techniques require a small incision to obtain access to the femoral artery. All of them involve doing a procedure from inside of the vessel without making further incisions on the leg. Balloon angioplasty is simply passing a catheter with a balloon on it down to an area of blockage and blowing up the balloon crushing the material inside of the artery out into the arterial wall. All the other techniques are variation son the balloon angioplasty. Some involve removal of a small amount of material from the inside of the vessel with or without subsequent angioplasty. Some involve the use of laser energy to reform the channel. All of these techniques are actively undergoing investigation at this time, none of them show any real advantages over simple balloon angioplasty with or without a stent. We expect that soon we'll be able to use a graft-covered stent, but these are not quite ready to be used at this time. If the narrowing is somewhere in the iliac area (inside the abdomen between the belly button and the groin) usually a stent placement gives the best and most durable results, the vast majority lasting for several years.

While endovascular procedures (PTA and stenting) are both effective and durable in the iliac area, they do not fare as well in the leg. Many times repeat procedure need to be done even as often as every six months or so. While this may sound bad just remember that it is done through a needle stick in the groin and does not usually require incisions. There is minimal "down time" (recovery period) and minimal discomfort. Many are done as outpatient procedures. It is also a way of delaying the need for an open procedure and increases the possibility that newer endovascular procedures will be developed to treat the entire problem in a minimally invasive manner. This is one of the most rapidly advancing fields in medicine.

The final approval by the FDA of the new stent grafts for repair of aneurysms has opened many new doors for us and promises even more rapid developments in ES. The endovascular repair of abdominal aortic aneurysms (AAA) is indeed a marvelous addition to our armamentarium. This allows us to repair at aneurysm from the inside of the artery by sliding the graft up through the vessels from the groin into the aorta. Most of the time it requires only a small incision in each groin. Everything else is done on the inside of the artery by x-ray control. Unfortunately, not all patients have appropriate anatomy for this to be done, but as newer grafts become available, this will probably become the preferred approach for the vast majority of aneurysm repairs. For further reading on this subject we would refer you to the following website:
www.guidant.com/patient/aaa as well as our own website.

Partial obstruction of the arteries supplying the kidney can result in a rise in blood pressure. This results in what we call renovascular hypertension. The involved kidney does not see the true blood pressure, but a lower one because of the obstruction. The kidney secretes a hormone which elevates the overall blood pressure so it can see a normal pressure itself. If this persists long enough, the high blood pressure can damage other organs of the body and the involved kidney can lose its function. Man times, we can either resolve the blood pressure problem or at least reduce it and we can preserve kidney function in the involved kidney. Balloon angioplasty works most of the time. Only when it fails will open surgery become necessary.

If the mesenteric arteries (the arteries supplying blood to the bowel so you can digest your food) become blocked, you may develop any of a complex of symptoms which include pain after eating, vomiting, diarrhea, loss of weight, or fear of eating because you know it is going to cause pain afterwards. While these are all common symptoms of many other common problems, with appropriate studies we can identify these blockages and usually approach them using balloon angioplasty techniques.

Complications
Problems associated with your anesthetic will be discussed with you by your anesthesiologist.

It is never nice to talk about the bad things that could happen when you have an operation. But, it is necessary that you understand that not always do thing go without a hitch. We will not make an attempt to cover all things that can happen, but will list for you the most common problems seen.

Whenever we do any operation for hardening of the arteries, the most common complications are other complications of the hardening of the arteries, whether or not they are associated with the surgical procedure. This happens because all the arteries are involved with the disease process and not just the one we are caring for at the moment. Therefore, heart failure, heart attack, stroke, or problems with the circulation in an arm or leg, kidney, or bowel may occur and result in serious consequences including the possibility of death. Pneumonia or other lung problems can occur, but are usually preventable if you follow instructions. As with any operation, bleeding problems and infections are also possible.

Groin wounds can be a problem, particularly in heavy individuals. Meticulous care needs to be focused here to avoid problems with wound breakdown and infection. Leg wounds many tiems will leak a clear yellow fluid (lymph) for a while. This is not unusual. The wounds, however, should not become red and the fluid should not become cloudy. If this happens, you need to let us know as soon as possible.

Failure of the reconstruction is also possible. If the procedure fails, the artery usually reverts to the same condition it was in before the surgery. But, if there is a clot that extends into the outflow system, it can become worse. While this is an uncommon problem, it can and does occasionally happen, and you must be aware of it.

There are many other minor problems that can and have occurred, but in a very low frequency. We'll be happy to discuss them with you in greater detail if surgery is recommended. Of course, you should feel free to ask us any questions you have concerning the surgery, its alternatives, and the potential complications.

So, what does the future hold? Investigations are currently ongoing to determine the effectiveness of a small filter placed above a lesion in the carotid artery that may enable us to treat a lesion in this artery (which supplies the brain with blood) using balloon angioplasty and stenting. Without the filter the risk of stroke is too high because of breaking off of debris released at the time of angioplasty. But these risks seem to be significantly reduced with the filter. This is not available for general use yet, but we are following these investigations very closely.

Miniaturization, inventive access techniques, new materials development, and unrestricted use of the imagination are all going to combine to open new vistas in interventional therapies.

These are exciting times!