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Peripheral Vascular Surgery Society
Patient Information with Questions and Answers about
common vascular diseases and their treatment
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Select the topic desired:
Common Questions about Endovascular Surgery:
Introduction
Common Questions about Endovascular Surgery and its
attendant procedures.
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Frequently Asked Questions: FAQ's
1. What is Endovascular Surgery?
Again, Endovascular surgery can be described as the treatment of vascular disease
from inside the blood vessel (endoluminal). This basic premise is not new, and
easily dates back to the first angioplasty treatment of blood vessels in the
1970's. Since that time technology has advanced at a rapid pace, and there are
numerous 'endovascular' options available to patients. Some of the more common
peripheral endovascular options include: 1) iliac artery angioplasty/stent 2)
Renal artery angioplasty/stent 3) lytic or mechanical clot removal therapy 4)
Aortic stent grafts.
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2. What are the benefits of Endovascular Surgery?
The key component that makes endovascular surgery attractive compared to conventional
surgery is usually related to recovery time and patient risk. Endovascular options
usually (but not always) have a lower risk than conventional surgical approaches,
and usually have shorter recovery times for the patient. Unfortunately, endovascular
procedures are often not nearly as durable (stay open or work) as many of the
conventional surgical approaches. Therefore, it is intuitive that the risks
and benefits of both endovascular and open surgical techniques be considered
ON AN INDIVIDUAL basis.
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3. Who does Endovascular Surgery?
Currently, there are several groups of physicians in some form or another involved
in endovascular procedures.
Surgeons include: 1) Peripheral Vascular Surgeons 2) Cardiothoracic
surgeons 3) General Surgeons
Radiologists include: 1) Interventional Radiologists 2) Interventional
Neuroradiologists
Internal Medicine Physicians include: 1)Interventional Cardiologists
2) Vascular Medicine Specialists
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4. Who should do my Endovascular Surgery?
This is a question that hasn't been answered by the medical field at this time,
nor will it be answered in the near future. The best guidelines for qualification
probably are based upon the newest recommendations from the major groups that
have credential recommendations to perform these procedures and they are the
Society of Cardiovascular and Interventional Radiology (SCVIR), Society for
Cardiac Angiography and Interventions (SCAI), American college of Cardiology
(ACC), Society of Vascular Surgery/International Society Cardiovascular Surgery
(SVS/ISCVS). When so many groups have guidelines, and they are all substantially
different, it becomes obvious that there will be no easy answers as to which
qualified practitioner should perform your specific intervention. The question
above is valid, but perhaps as important or more important is "Who should decide
when I should have endovascular surgery?".
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5. OK, Who should decide when I should have endovascular surgery?
Actually this question is the most important to ask in our opinion. The first
intervention into the peripheral vascular system can be the most important in
that it can change a relatively innocent problem, or finding, into a limb or
life threatening one down the road. Informed consent (the sheet of paper that
you sign before the doctor does something) involves not only a discussion about
the risks and benefits of a particular intervention, but also a discussion about
the risks and benefits of other treatment options. When you ask your physician
the questions about those factors they should be able to give an informed/educated
answers and discuss the options available for different forms of treatment,
some of which they may not perform. To date, there is only one group of specialists
that must attain and demonstrate this knowledge to be board certified/board
eligible in their respective specialties, the Peripheral Vascular Surgeon (via
the American Board of Surgery). While the actual intervention may be performed
by anyone from a number of specialties, and perhaps not by the peripheral vascular
surgeon in particular, the training requirements for this specialty require
an understanding of the options and outcomes for peripheral vascular treatments.
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6. What is an angioplasty?
An angioplasty is a technique used to dilate a stenosed artery with a balloon
catheter. The angioplasty balloon (deflated) is placed across the area of arterial
narrowing and then inflated to dilate the blood vessel. This technique has been
used in various vascular beds throughout the body, one of the most common is
the coronary arteries (heart) and the iliac arteries (arteries to the legs).
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7. Why did the Angioplasty not work?
Angioplasty treatment depends upon many factors. The narrowed portion of the
blood vessel must be accessible to the balloon. The blood vessel must be such
that the balloon can 'crack' or dilate the substance of the blood vessel. Also,
there is a risk of tearing the artery inside (dissection) that can result in
acute closure of the artery. The blood vessel after such dilation can have an
intense scarring reaction (intimal hyperplasia) that can cause it to scar closed.
Also, many vessels in the body react differently based on size and their blood
flow capacity. Importantly, continued smoking and tobacco abuse accelerates
the intimal hyperplastic response, leading to rapid rates of recurrence.
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8. What is a Stent?
A stent is a device used to hold open the wall of a vessel or to hold something
in place in the vascular system usually with or after angioplasty. These devices
are usually metal mesh in nature and are either expanded by angioplasty balloons
in place or self-expand when deployed.Their deployment may allow an angioplasty
technical failure to be retreived and salvaged. However, there is a paucity
of data supporting the concept that stents markedly improve long term patency
in peripheral vessels.
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9. I have an aortic aneurysm and was wondering what the options were for treatment?
There are several options for treatment of aortic aneurysms. Here again, understanding
the risks and benefits of the different forms of treatment options are critical.
For the remainder of the discussion we will consider aneurysms limited only
to the abdomen in the most common configurations, and descending, ascending,
and thoraco-abdominal aortic aneurysms will not be included. The options for
treatment of Abdominal Aortic Aneurysms (AAA) include:
Observation: The risk of a small abdominal aortic aneurysm (less than
4.5cm) resulting in significant problems is low and in general below this size
it is felt that the risk of repair is higher than the risk of the aneurysm.
In aneurysms, size does matter, and the risk of an AAA causing problems is dependent
upon the diameter of the aneurysm. In general, open repair is an option when
the aneurysm reaches a minimum diameter of 4.5-5.0cm. Since patients with significant
other medical problems can be higher risk for repair, the size that the repair
is less risky than the aneurysm depends upon the patient. Repair of small aneurysms,
less than 4.5cm, that are not causing problems or growing rapidly is not indicated
by any method. Serial cat scans (CT's) or Ultrasounds are generally used to
follow small aortic aneurysms. If the aneurysm grows significantly (0.5cm in
diameter in 6 months, or 1cm in a year), causes pain or other problems, or grows
to a diameter that the risk of repair is less than that of the aneurysm, then
repair of the AAA is indicated.
Open Surgical Repair: This is the gold standard for treatment of AAA
that has indication for repair. The risk of open surgical repair of a AAA includes:
Death, heart attacks, limb loss, organ ischemia or organ loss (especially the
large bowel), sexual dysfunction in males, bowl injury, embolization, wound
problems, graft infections, graft erosions, renal failure/dysfunction. The accepted
death rate for repair of an AAA is 2-5%, but can be higher or lower if the pelvic
or renal arteries are involved and the extent of involvement of those vessels.
Also, a patient's comorbid conditions can affect the outcome. Follow-up requirements
are usually only to bi-yearly or yearly visit to the surgeon who performed the
procedure.
Endovascular Repair: Endovascular grafting, via groin punctures or
incisions, is the newest treatment for AAA disease. The repair holds promise
to decrease the death and complication rate associated with open surgical repair,
and to get patients home and back to work quicker. The procedure seems to be
a success in getting patients out of the hospital quicker, but has not been
shown to decrease the death rate compared to open surgical repair. Unfortunately,
there is no long-term data on either FDA (Food and Drug Administration) approved
(Aneurex and Ancure) aortic endovascular graft for this repair. Also, there
have been troubling recent reports of aneurysm rupture and patient death with
these devices in place, and this risk may be increasing the further out from
repair the individual gets from implantation. The follow-up requirements for
endovascular grafting have not been well established, but seem to require CT
scans , plain x-rays (multiple views), and perhaps ultrasound studies, roughly
every 4-6 months for the remainder of the patient's life. Also, there is a continued
risk that further endovascular interventions will be needed to keep the grafts
functional. While endovascular grafting may be beyond the 'experimental' stage
of development it exact place in the scheme of treatment of AAA for individual
patients has yet to be well delineated.
The person or team who does your abdominal aortic aneurysm, whether open or
endovascular, should be capable of dealing with the most common problems that
develop with the procedure. The risk of conversion to open operation is between
1-5%, the need for surgical exposure of the groin arteries is nearly 100%, and
the risk of complex repair of the femoral arteries is common. Having a board
eligible/board certified peripheral vascular surgeon assures that the individual
is capable at dealing with the common problems that develop with this technique
or an institution with defined excellence in this arena. The patient considering
this technique must specifically ask who will treat the most likely scenarios/complications
associated with AAA graft implantation. The devices are being implanted by individuals
who may not have experience with peripheral vascular disease, AAA treatment,
or any specific surgical experience, in a setting (catheterization laboratories
without surgical equipment or lighting) were emergencies (aneurysm rupture,
limb ischemia, arterial injury, and bleeding) cannot be adequately treated.
We personally recommend that anyone considering this alternative for treatment
of AAA ask about how these common outcomes will be dealt with.
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Peter S. Dovgan, M.D., for the PVSS
We at the PVSS hope this information as answered what may be some of your questions
about Endovascular Surgery and Endovascular Therapy.
Last updated 10/26/2000 Copyright 2000 Peripheral Vascular Surgery Society
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