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The management of vascular disease has seen a shift in practice from open surgery to minimally invasive endovascular intervention. Outline the advantages related to this transition and future challenges with reference to aortic, carotid, peripheral vascular, and venous surgery.
Treatment approach of surgeons towards vascular patients has changed vastly over the last few decades. As a rapidly evolving specialty with technological advances, vascular surgeons now have more options and approaches to target treatment to patients. The practice is rapidly shifting with minimally invasive technologies embraced by many surgical disciplines over the past few years with a consequent reduction in morbidity and mortality, as well as allowing many patients unfit for conventional surgery to undergo. Endovascular intervention can be offered in several disease processes involving the aorta, carotid arteries, peripheral vasculature as well as veins. However, this shift to endovascular is not without its disadvantages and thus it is crucial for a surgeon to approach patient care with both open and endovascular approaches in mind and tailor care to individual patients.
Open aortic surgery for treatment of thoraco-abdominal aneurysms or occlusive disease was the preferred method up until 2005 where a paradigm shift was seen towards endovascular approaches (1). Open aortic repair (OAR) is considered high-risk and not a suitable option for all patients, hence the advantage of endovascular treatment. The idea of treating aortic disease without the need for a general anaesthetic, laparotomy incision and clamping of the aorta made endovascular treatment an attractive option for surgeons and patients alike. Treatment of such disease remotely with insertion of custom-stent grafts and mortality and morbidity outcomes comparable to open surgery lead to the wide adoption of the endovascular approach. The EVAR-1 and DREAM trial showed 30-day mortality rates were 1.7% in the endovascular group, compared to 4.6% in those that underwent open, with long term survival rates quite comparable, 89.7% and 89.6% respectively (2,3). Although EVAR has shown to be superior to OAR in short-term outcomes, it isn’t without its disadvantages. Patients who undergo a EVAR require life-long surveillance using imaging, as a definitive safety period of no surveillance has not yet been established with reintervention rates appearing to be higher in the EVAR group. From this, one could infer that EVAR is a more suitable option for older patients where the short-term outcome is more desirable than the long-term. However, these findings could be attributed to the fact that these trials commenced in the 1990s with inferior stent-graft technology used compared to current times. Since then there have been significant technological advancements in stent-grafts to minimise complications and courses dedicated to the upskilling of surgeons in EVAR. Thus, further research is required in the use of these newer devices and their long-term outcomes, as well as the development of devices to treat complications related to EVAR.
Treatment of carotid disease is mostly based on the guidelines formed from two large trials, the ECST and NASCET. Carotid disease for the prevention of stroke is an area of interest for vascular surgeons, and an area of contentious debate on which treatment approach is superior, carotid endarterectomy (CEA) and carotid artery stenting (CAS). The evidence of both the aforementioned trials, do largely favour CEA in the treatment of carotid stenosis for stroke prevention. This is further supported by the abandonment of two trials, SPACE and EVA-3S trials due to the high stroke and death rates secondary to CAS compared to CEA, 9.6% to 3.9% respectively (4). However, the level 1 evidence favouring CEA over CAS were based on outdated technology for CAS. Since, major advances in stent and embolic protection device technology have been made, and we may see a shift in the outcomes and use of CAS in symptomatic carotid disease with future research. Such improvements include better embolic protection systems using cessation or reversal flow systems during the stenting process (5). Additionally, avoidance of aortic arch manipulation and transit time via cervical access reducing embolization and manipulation through diseased and tortuous vessels. CAS is particularly useful in patients with difficult and tortuous anatomy and high carotid bifurcations not amenable for CEA, thus good technical skills and devices are fundamental to its success (5). It has been difficult amongst surgeons and neurologists for CAS to gain widespread approval with CEA being favoured, however with time and advances in technology there is promise for the use of CAS as an effective method of treatment for symptomatic carotid disease.
Treatment of peripheral arterial disease (PAD) has seen tremendous leaps and bounds over the past couple decades. With bypass not being the usual first line treatment in most cases, surgeons are opting for endovascular therapy (EVT) as first line treatment for critical limb ischaemia where possible. For treatment of PAD there are many options available with the use of stents, drug-eluting balloons and stents (DEB and DES), atherectomy devices and sub-intimal devices such as outback and pioneer. Physicians can achieve symptomatic relief and primary patency rates comparable to that of bypass surgery. The advantages of EVT is reduced mortality, hospital length of stay and wound infections that are associated with bypass surgery. For instance, in the treatment of iliac artery disease, which previously would be treated with a high-risk bypass procedure, a study looking at the Wallstent endoprothesis demonstrated primary patency rates of 95% at 12-months and 88% at 24-months (6). EVT is not without its complications and are usually associated with the access site, and they include haematomas, pseudoaneurysms, distal occlusions but these are now being mitigated by advances in closure devices. With further research going towards new stent-designs and materials as well as their pharmacological properties, it is beginning to shape the way we approach infra-inguinal arterial lesions. The use of DEBs, such as ELUVIA and IN.PACT have shown extremely promising results with patency rates and limb-salvage, with the mantra of “leave nothing behind” well and truly alive. The future of treatment in iliac and infra-inguinal disease is promising. Clinicians are beginning to use multiple modalities in their treatment approaches in complex, heavily calcified vessels that previously could only be treated with bypass surgery. One example of this, is the use of atherectomy devices in conjunction with balloon angioplasty or stents. Atherectomy devices in conjunction with EPD are used to prime the vessel wall making it suitable for deployment of a DEB or stent. The new wave of EVT is looking to the future with the development of smart stents with in-built pressure and flow detectors which feedback to an external monitoring system about dynamic changes in flow through the device, allowing for stenosis to be detected sooner rather than later. This type of technology would be particularly useful in patients where X-rays such as CT or diagnostic angiograms, which are the standard tools for diagnosis, that can be impractical or inconvenient for the patient (7).
Venous disease is another area that has always been challenging for surgeons in treating. Venous occlusive disease secondary to deep vein thrombosis and varicose veins are the two main areas that draw most of the attention. Surgical management of extensive deep vein thrombosis is a controversial topic amongst surgeons. Surgical treatment options include mechanical thrombectomy, catheter-directed thrombolysis (CDT) and stenting of lesions, with the latter not yet widely adopted. The primary objective is usually vessel patency and reducing incidence of post-thrombotic syndrome (PTS). The jury is still out there for when to treat such disease surgically or conservatively with anticoagulation. However, there are several studies, especially one by Kucher et al. (8) with favourable outcomes. Kucher was able to demonstrate that venous stenting after 15 hours of CDT had a primary patency rate of 96% and PTS of 6% compared to 67% patency and 40% respectively as seen in the CAVENT study, a large randomised-control trial looking at CDT (8,9). The challenge in venous stenting is that there have been no real dedicated stents made exclusively for venous disease. Current stent systems used are those that have been designed for arterial deployment. The most common used stents include Wallstent, Zilver, SMART and Protégé to name a few. Each with their own specific advantages and disadvantages that are chosen for use based on surgeon preference.
The future is bright for vascular and endovascular surgery. With many treatment options available, it is now becoming much easier for surgeons to tailor treatments to individual patients. We are still in the early days of endovascular surgery, with significant advances already made in the treatment of AAA, PAD, carotid and venous disease. As training programs begin changing with a more focused emphasis on endovascular surgery we will begin to see a more widespread adoption of endovascular surgery as first line treatment in both arterial and venous diseases.
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- Endovascular aneurysm repair trial participants. Endovascular repair versus open repair in patients with abdominal aortic aneurysm (EVAR Trial 1); Randomised controlled trial. Lancet. 2005; 365; 2179 – 2186.
- Blankensteijn JD, de Jong SE, Prinssen M, van der Ham AC, Buth J, et al. Two year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2005; 352: 2398 – 2405
- Diab. J., Gan. J. A Shift in Practice from Open to Endovascular Interventions: The Challenges for Future Practice. Avid Commentary. 2018.
- Veith, F. J. A Brighter Future for Carotid Stenting? October 26, 2015
- Vorwek D, Guenther R, Schurmann K, Wendt G, Peters I. Primary stent placement for chronic iliac artery occlusions follow up in 103 patients. Radiology. 1995; 194: 745 – 749
- Xing C., Babak A., York H., Kenichi T.. Medical Implants: Enabling Angioplasty-Ready “Smart” Stents to Detect In-Stent Restenosis and Occlusion (Adv. Sci. 5/2018). Advanced Science, 2018; 5 (5): 1870027 DOI: 10.1002/advs.201870027
- Kucher, N. Deep-Vein Thrombosis of the Upper Extremities. N Engl J Med. 2011; 364:861-869. DOI: 10.1056/NEJMcp1008740
- Enden T, Haig Y, Klow N, et al. Long-term outcomes after additional catheter-directed thrombolysis versus standard treatment for acute iliofemeral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet 2011; 379:31-38
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