Perspectives in Vascular Surgery and Endovascular Therapy

Indications for endovascular aneurysm repair cannot be considered absolute. Patient selection depends on the availability of product, the skills and experience of the implant team, and the anatomy and overall condition of the patient. It is unclear if these procedures should be offered to all those with large aneurysms, restricted to high-risk or low-risk patients, or offered to patients with smaller aneurysms not currently considered for operation. More patients will be suitable as more devices become available, skills improve, sheath sizes decrease, and long-term data showing efficacy become available. Significant anatomic factors affecting patient selection include the length, shape, and angulation of the infrarenal neck, any involvement of the common iliac arteries with either aneurysmal or occlusive disease, occlusive disease or marked tortuosity of the ileofemoral access vessels, or intrinsically small iliac arteries.

Early results indicate that the procedure is at least as safe as conventional repair, and patients can return to normal activities sooner. What we do not know is whether the natural history of aneurysms (i.e., death from rupture) is altered by an endovascular device. We are just learning the failures modes, and some were not anticipated in the design phase. We do not know if progressive dilatation of the attachments sites and aneurysm remodeling will result in device migration but the US IDE experience and reports from Europe suggest that these phenomena will occur. Our early experience suggests that we should avoid endografting in young, otherwise healthy patients with long life expectancies.

Pulmonary embolism (PE) remains a leading cause of death among hospitalized patients, and it is well accepted that fatal PE can be prevented by the placement of an inferior vena cava (IVC) filter. The progressive refinement of percutaneous insertion techniques for placement of IVC filters has led to a more widespread use of these devices, particularly in high-risk patients in whom other forms of prevention have been ineffective. Even percutaneous insertion, though, has required fluoroscopic guidance with the need for patients to be moved to an operating room or interventional suite. The transport of critically ill or multitrauma patients requires numerous ancillary staff, which is costly and may be hazardous. Advances in color-flow duplex ultrasound scanning have allowed routine imaging of the iliac veins, and the IVC and IVC filters can be visualized by duplex scan. This combined with the portability of modern ultrasound equipment allows bedside insertion of an IVC filter using ultrasound guidance alone. When technologically feasible, rapid, accurate placement of an IVC filter can be performed without moving the patient from the critical care environment. This strategy reduces the complexity of managing these patients and may also reduce the costs and the overall risks of the procedure. This discussion reviews the indications, technique, complications, and some early follow-up of duplex ultrasound-guided IVC filter insertion (DGFI).

Development of stent-graft endovascular exclusion has forever changed the management of aortic aneurysms. This new modality is most advantageous for AAA patients who are at high risk for standard open repair. They, in turn, are more likely to present with challenging neck and iliac artery anatomy that may increase the likelihood of failure, and even preclude endoluminal therapy altogether. A complete understanding of critical anatomical issues and available troubleshooting adjunctive techniques is paramount if we are to expand applicability of stent-graft technology to increasing numbers of "difficult" patients with large aneurysms.

Acute aortic dissection is one of the most common catastrophic events that affects the aorta, and, even in the best of circumstances, morbidity and mortality remain high. The majority of aortic dissections involving the descending thoracic aorta can be successfully managed with medical therapy. However, even with aggressive medical therapy, the associated mortality approaches 20%, and a significant number of patients die within a year from complications related to the dissection. Operations for descending thoracic aortic dissection are reserved for patients who fail medical management and develop complications such as aneurysm formation, aortic rupture, branch vessel malperfusion, or refractory pain. Patients who require operative intervention for acute descending thoracic aortic dissections have a worse outcome, with mortality rates near 35%. Mortality is higher in patients who require operative intervention specifically for ischemic complications related to dissection. It is in this group of patients that new, less-invasive methods of endovascular treatment have been promoted with great enthusiasm. Furthermore, early success of endovascular techniques in treating ischemic complications of distal aortic dissection raises the question: Should such patients be managed with traditional open surgical operation or newer endovascular therapies? This article summarizes the anatomy and natural history of descending thoracic aortic dissection, focusing on the development of ischemic complications, comparing and contrasting the role of open surgical operation to endovascular therapy.

There has been a dramatic increase in the interest and profile of endovascular aneurysm repair over the past 10 years. The early results following endovascular repair are promising, however, the durability of this technique is not yet known. Leaving that issue aside for the time being, there is increasing controversy with regard to who is best qualified to perform the intervention—vascular surgeons, interventional radiologists, or cardiologists. Dr. Kim Hodgson, a vascular surgeon, and Dr. Stuart Geller, an interventional radiologist, will be debating the question, "Who should be performing endovascular interventions?" Each will have 10 minutes to make an argument on behalf of their respective specialty, followed by three to four minutes of rebuttal. The debate will then be open to the floor for general discussion.

In the last few years surgical treatment of carotid artery stenosis to prevent strokes has been challenged due to improved medical treatment and widespread performance of balloon angioplasty and stenting. We asked four experts from varying specialties to address this critical issue. William Baker, M.D. is Chief of Vascular Surgery at Loyola and will provide an overview of surgical treatment of carotid artery disease. Barry Katzen, M.D. is a radiologist and Chief of the Miami Vascular Institute and will discuss appropriate candidates for and results of carotid balloon angioplasty and stenting. Irene Meissner, M.D. from the Mayo Clinic will provide her opinion when carotid intervention is indicated from a neurologist's viewpoint and also discuss newer anti-platelet agents used to prevent stroke. Christopher Zarins, M.D. is Chief of Vascular Surgery at Stanford University and will discuss the high-risk surgical patient and re-do carotid surgery.

This session was designed to address a controversial but critically important issue facing vascular surgeons, radiologists, cardiologists, and primary care physicians. We believe the discussion session that followed these intriguing presentations confirmed the difficult and controversial aspects of treating carotid artery disease.