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Combining endovascular, open surgical approaches may provide benefits of both for some patients
Improvements in imaging technologies have also helped the development of endovascular procedures.
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Vascular Interventional Advances
Combining both endovascular and open surgical approaches to revascularization in certain patients may help optimize the outcomes.
According to a presentation given at the Vascular Interventional Advances 2009 meeting in Las Vegas, recent technological developments and a growing body of literature have helped bolster endovascular approaches to revascularization as a potential adjunct to traditional open surgical approaches in certain clinical situations. Recent advancements in imaging technologies have also aided vascular specialists in their ability to perform endovascular procedures.
“This concept of combining imaging with open vascular surgery has been fostered by a number of advances, one of which has been improved fluoroscopic and sonographic imaging in the operating room,” Peter Schneider, MD, a vascular surgeon with the Hawaii Permanente Medical Group in Honolulu, said in his presentation. “It is no longer unusual to begin a case not with an incision, but with imaging.”
Schneider said that nearly 80% of the interventional procedures performed in his practice are either stand-alone endovascular or imaging-guided open endovascular surgical procedures. Ultrasound imaging of the bifurcation, for example, can be used before performing a carotid endarterectomy to help the physician make more precise incisions. Schneider also traced the recent historical development of the endovascular approach and noted its gradual acceptance over time during the incorporation of stent technologies in the 1990s, as well as advances in stent grafts and carotid artery stenting developed in the early 2000s.
Increased utility of endovascular procedures
Schneider suggested that combing the endovascular approach with the open surgical approach can be useful in a variety of clinical situations.
Common femoral artery disease with either inflow or outflow lesions was cited as an appropriate setting for the hybrid approach, as was the presence of an inflow lesion requiring percutaneous transluminal angioplasty or a stent with distal bypass. Balloon control of ruptured abdominal aortic aneurysms, Schneider said, evolved from performing endovascular repair of abdominal aortic aneurysms.
Schneider also highlighted several cases from his practice as examples of both endovascular and open surgical approaches being used in concert to achieve better procedural success in patients requiring revascularization of their lower extremities. One cited case included a patient who underwent percutaneous transluminal angioplasty of the superficial femoral artery with a distal stent bypass. At two years, Schneider reported 72% patency with a long stent bypass and 76% patency with the combined endovascular procedure.
“We do not have all of the answers, but these combined procedures seem to work,” Schneider said. “The use of the best that each technique has to offer, to employ that technique strategically and to do the least harm for the greatest benefit is the clear advantage here. Although I have presented a small minority of procedures here, these combined procedures are often used for the worst lesions and in segments most in need of revascularization.”
For more information:
- Schneider P. Presented at: Vascular Interventional Advances; Oct. 20-23, 2009; Las Vegas.