The evolution of percutaneous strategies for endovascular aneurysm repair

Baylor St. Luke’s Medical Center in Houston recently celebrated the 20th anniversary of the first-ever percutaneous endovascular aneurysm repair which was performed at the hospital June 4, 1996, by Zvonimir Krajcer, MD.

Since then, “we have done more than 2,000 percutaneous endovascular aneurysm repair procedures, with very good results,” Krajcer, program director of peripheral vascular interventions as Texas Heart Institute and Baylor St. Luke’s Medical Center, told Cardiology Today’s Intervention. “Our goal is to educate physicians in the United States and abroad about this technique and to popularize it so it can be used by almost all operators.”

History of PEVAR

The first endovascular aneurysm (EVAR) procedure was performed in 1990 by Argentine physician Juan C. Parodi, MD. Although it was less invasive than traditional open surgery, EVAR required surgical incision in the groin and general anesthesia.

Zvonimir Krajcer

“At that time, the stent grafts we used were about 8 mm in size, which was painful and required general anesthesia,” Krajcer said in an interview. “My goal was to reduce discomfort for our patients because surgical incisions and general anesthesia carry risks, particularly in patients who have significant comorbid conditions such as CAD, HF, diabetes and many other conditions.”

Krajcer designed a smaller graft (14F, or 4.7 mm in diameter), which could be placed via a percutaneous approach using only two small puncture sites at both groins.

We did that first percutaneous EVAR (PEVAR) in 1996 under local anesthesia with just mild sedation and numbing medication,” he said.

Additionally, the procedure was done in the catheterization lab rather than an OR, which is typically where EVAR procedures are performed.

“Procedures done in the operating room are three to six times more expensive than those done in a cath lab or an interventional suite,” Krajcer said. “OR procedures require more personnel, and whenever you have more personnel, the costs are higher. Additionally, PEVAR does not require the patient to be transferred to the recovery room or ICU, which is also significantly costlier than transfer to a regular room.”

Use today

Krajcer has served as the principal investigator on two clinical trials that have validated the PEVAR approach. Results of the first, the randomized PEVAR trial, were published in 2014 and showed a significant reduction in complication rates with a percutaneous approach vs. a surgical approach. Preliminary results of the second trial, the LIFE trial, have been published, and final results are expected to be published soon, Krajcer said.

“This trial showed, again, that there are great benefits to the use of a percutaneous approach and general anesthesia, but it also showed that we can save close to $4,000 per patient in costs to the hospital if we do this procedure under the least invasive approach and in so-called ‘fast-track’ protocol, which means discharging the patient from the hospital within 23 hours after the procedure.”

As it is currently performed, PEVAR enables a much shorter recovery time for patients, eliminating grogginess and nausea caused by general anesthesia and enabling patients to ambulate within 4 hours after the procedure.

Krajcer said the adoption of PEVAR has increased significantly since its introduction in 1996. Ten years ago, roughly 2% of operators were performing PEVAR, whereas today almost 60% of operators use this approach, he said.

Krajcer said his goal is to encourage more widespread adoption of PEVAR in coming years. He hopes that the procedure will soon acquire a billing code so hospitals and operators can be reimbursed for PEVAR.

“In 1996, this was a novel procedure, and there was a significant skepticism about it and a concern for patient safety. Now, we have proven in multiple publications that this approach not only saves money for hospitals, but is also a great benefit to patients,” Krajcer said. “This approach is not only fast-track EVAR but also the least invasive EVAR, and I think it will become the gold standard for the treatment of EVAR patients.” – by Jennifer Byrne

References:

Krajcer Z, et al. J Cardiovasc Surg. 2011;52:651-659.

Krajcer Z, et al. Texas Heart Inst J. 2013;40:560-561.

Nelson PR, et al. J Vasc Surg. 2014;doi:10.1016/j.jvs.2013.10.101.

For more information:

Zvonimir Krajcer, MD, can be reached at 6624 Fannin St. #2780 Houston, TX 77030; email: zkrajcer@leachmancardiology.com.

Disclosure: Krajcer is principal investigator of the PEVAR and LIFE trials and reports speaking for Endologix.