Perspectives in Vascular Surgery and Endovascular Therapy

The Society for Vascular Surgery surveyed primary care physicians (PCPs) to understand how PCPs make referral decisions for their patients with peripheral vascular disease. Responses were received from 250 PCPs in 44 states. More than 80% of the respondents characterized their experiences with vascular surgeons as positive or very positive. PCPs perceive that vascular surgeons perform “invasive” procedures and refer patients with the most severe vascular disease to vascular surgeons but were more than twice as likely to refer patients to cardiologists, believing they are better able to perform minimally invasive procedures. Nevertheless, PCPs are receptive to the notion of increasing referrals to vascular surgeons. A successful branding campaign will require considerable education of referring physicians about the totality of traditional vascular and endovascular care increasingly provided by the contemporary vascular surgical practice and will be most effective at the local grassroots level.

Carotid artery stenting is an alternative to carotid endarterectomy. Although the stroke and mortality rates after stenting are low, it is yet to be proved that stenting is superior or equal to endarterectomy in low-risk symptomatic and asymptomatic patients. A summary of the results of 2 recent trials comparing carotid stenting with carotid endarterectomy, SPACE, and EVA-3S, is presented herein. Both trials failed to prove noninferiority of carotid stenting compared with carotid endarterectomy.

With the development of equipment specifically designed for carotid artery stenting (CAS) and a national effort to train specialists, CAS has blossomed into a viable alternative to carotid endarterectomy (CEA) in certain circumstances. Not without risks, stroke is a well-recognized complication of CAS; yet a variety of other unique problems can complicate an expected successful outcome. This review covers some of the more common problems and provides potential solutions to preventable situations that may occur in the periprocedural period. The primary objective of this review is to provide a heightened awareness of both anticipated and unanticipated risks of the procedure, with the hope of avoiding recurring problems.

The role of platelets and the importance of platelet inhibition are well established in patients with vascular disease. When physicians perform revascularization procedures in these patients, who typically have the most advanced atherosclerotic disease, they should be aware of both the generic benefits of platelet inhibition on patients' long-term health as well as the specific benefits relative to operative or endovascular revascularization. Platelet inhibition has not been well studied in the aortoiliac system, renal vascular bed, or the mesenteric arterial bed. Peripheral vascular beds that have been studied are predominantly the carotid circulation and the infrainguinal vasculature. This article reviews the basic mechanisms of platelet inhibition and suggests antiplatelet strategies for vascular interventions, including carotid endarterectomy, carotid angioplasty and stenting, infrainguinal bypass, and peripheral angioplasty and stenting.

Peripheral arterial disease has a significant impact on the quality of a patient's life. Pain, fear of limb loss, increased inactivity, and poor lifestyle choices such as continued smoking further debilitate these patients. Surgical and endovascular procedures have affected this outcome for many but carry the added risk of procedural complications and mortality for this group of high-risk individuals. Risk factor management and medical therapy carry little risk and can also improve functional outcome for many of these patients. Despite this, there are currently only two FDA-approved medications for the treatment of claudication. This review discusses published data on the impact of walking distance with investigational pharmacotherapy.

Autologous stem cell-based therapy offers many advantages over other nonsurgical treatments of peripheral arterial disease. Transplant stem cells are a renewable source of multiple cytokines and growth factors. Autologous adult stem cells are not rejected and do not form teratomas. Early preliminary results indicate that adult stem cell therapy is safe and effective in patients with critical limb ischemia.

Kissing stent reconstruction of the aortoiliac bifurcation is a widely used technique for the management of aortoiliac occlusive disease involving the aortic bifurcation or proximal common iliac arteries. New advances in delivery systems and stent design have enabled better anatomic results with kissing stenting. Long-term patency is generally excellent, although several factors may adversely affect patency and should be taken into account when devising the stenting configuration and selecting the device to be used. Geometric variables related to individual aortic anatomy and disease pattern (patient dependent) and stenting configuration (operator dependent) may have an impact on long-term patency. Kissing stent aortoiliac reconstruction is effective and durable, even with complex aortoiliac disease and long-segment occlusions. In our experience, TASC (TransAtlantic Inter-Society Consensus) C and D class disease is not necessarily a contraindication to aortoiliac stent reconstruction, especially in poor operative risk patients. Most restenoses are amenable to endovascular treatment, with excellent long-term assisted patency.

The benefits of the use of embolic protection devices (EPDs) in saphenous vein coronary artery bypass grafts and carotid arteries have been shown, but the utility of their application during infrainguinal endovascular interventions is somewhat unclear. Patients with specific anatomical features or lesion characteristics, or patients undergoing specific types of endovascular interventions may benefit from the off-label use of EPDs, but this has yet to be determined. This report will examine the current literature related to the use of EPDs in infrainguinal endovascular interventions and attempt to identify the patients who would most likely benefit from their use. In addition, the setting in which EPDs have been used at one institution is briefly described. This discussion will serve as a general guideline for the use of EPDs and act as an impetus for the development of future clinical trials to help elucidate the patients who will truly benefit from EPDs use when undergoing lower extremity endovascular revascularization procedures.

Foam sclerotherapy offers a treatment strategy with great potential. Recently, general and vascular surgery have become less invasive; so too, has the treatment of venous disorders. Sclerosants cause irreversible damage to the vascular endothelium by disrupting cell membranes resulting in sustained vasospasm and denudation of the venous monolayer. Prospective randomized outcome data support the hypothesis that foam sclerotherapy is superior to liquid sclerotherapy. All published reports of varicose vein treatment with foam describe efficacy in terms of immediate and primary venous occlusion of better than 80%. Severe complications of foam sclerotherapy are rare. Recurrent varices are in the 10% to 20% range. Use of foam sclerotherapy in our experience has proven to be effective, essentially pain-free, and durable in the short term. The treatment is quick, efficient, and cheap.

Endovenous modalities to treat superficial venous reflux of the lower extremities have revolutionized management of patients with varicose veins. Laser and radiofrequency probes have both found their way into the arsenal of physicians treating venous reflux. Although both offer distinct advantages and minor drawbacks, they each offer the convenience of in-office treatment, faster recovery, and improved safety over traditional surgical procedures. This article will briefly discuss the technique, treatment results, and potential complications associated with each procedure.

Venous ulceration of the lower extremities is a common and often disabling condition. Venous ulcers are the result of a chronic inflammatory condition caused by persistent venous hypertension. Therapy is directed at counteracting the chronic inflammation in the tissues and at decreasing ambulatory venous hypertension in the area. Compression therapy helps decrease the venous hypertension and aids healing. Topical agents may be used to help decrease the bacterial load in the wound, provide a moist healing environment for dry wounds, or absorb the exudate in wounds with a lot of drainage. Pharmacological adjuncts, such as pentoxifylline or flavanoids, may help counteract the chronic inflammation in the ulcerated area. Interventions to decrease the ambulatory venous hypertension can help patients with either active or healed ulcers. Ablation of incompetent superficial truncal veins and/or perforating veins using radiofrequency ablation, endovenous laser ablation, or foam sclerotherapy can speed ulcer healing and prevent recurrence.

The past decade has witnessed new developments for the treatment of deep venous thrombosis (DVT) as well as more information about the virulent nature of DVT over the long term. Symptoms of pain, edema, skin changes, and/or ulceration can affect upwards of 70% of individuals to some degree. Studies have determined that early intervention of thrombus removal may help prevent postthrombotic syndrome in a significant number of patients. Several devices now specifically combine mechanical or ultrasound energy with chemical thrombolysis. These devices include the Trellis-8, Angiojet Power Pulse System, and the Ekos Endowave. Other important aspects central to successful endovascular removal of DVT include using ultrasound guidance for access, understanding venous anatomy and physiology in relation to endovascular techniques, knowing when to perform venous interventions, and using intravascular ultrasound. Endovascular removal of DVT is increasingly becoming the standard of care, particularly that affecting the iliofemoral segments.

available at http://www.neurology.org/cgi/ content/abstract/68/3/195

available at http://circ.ahajournals.org/cgi/ content/abstract/114/21/2226

available at http://www.pubmedcentral.nih .gov/articlerender.fcgi?artid=1876984

available at http://cat.inist.fr/?aModele= afficheN&cpsidt=18384057

available at http://www.circ.ahajournals.org/ cgi/content/abstract/114/24/2679

available at http://ats.ctsnetjournals.org/cgi/ content/abstract/83/2/592