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December 2011 Vascular Newsletter >>
Minimally Invasive Vascular Surgery: Trends and Outcomes
Minimally invasive techniques to treat lower extremity vascular disease, abdominal aortic aneurysm, and carotid artery stenosis continue to evolve as endovascular technologies improve. Learn about outcomes data for these techniques, and when they are—or are not—more appropriate than open surgery.
Lower Extremity Vascular Disease
Open surgical bypass has traditionally been the “gold standard” treatment for lower extremity vascular disease: surgeons can achieve 5-year patency rates of up to 70% with a saphenous vein bypass.
Unfortunately, open bypass can be associated with significant morbidity and mortality, and can have a considerable negative impact on quality of life. Less than half of open bypass patients regain baseline function within 6 months of surgery.
Percutaneous interventions, such as balloon angioplasty (with or without stenting), excisional atherectomy, drug-eluting technologies, or laser ablation, appear to offer patients reduced morbidity and mortality and an improved quality of life. Advances in technology also allow surgeons to perform even more anatomically challenging procedures than before.
A recent study reviewed the outcomes of 1000 percutaneous interventions for patients with disabling claudication and limb-threatening ischemia (1). Key findings included:
Although percutaneous revascularization requires more re-intervention than open bypass, minimally invasive approaches should be considered first-line treatment for patients with lower extremity vascular disease.
Abdominal Aortic Aneurysm Repair
Endovascular repair (EVAR) is now an established treatment option for abdominal aortic aneurysms (AAA). In the past 5 years, it has surpassed open aortic repair (OAR) as the treatment of choice for many older or high-risk AAA patients.
This trend is in part due to the reduced risk of short-term postoperative complications associated with EVAR. For example, the rate of cardiac complications with EVAR is 2.8%, compared to 8.9% with OAR. Similarly, the rate of respiratory and bleeding complications with EVAR is 2.6% and 8.7%, respectively, compared to 14.5% and 17.1% with OAR.
Longer-term complications associated with EVAR, however, can include endoleaks, rupture, and occlusion. EVAR also requires more frequent monitoring and re-intervention, and can therefore be more costly.
Two major randomized trials—EVAR-1 (2) and DREAM (3)—evaluated EVAR versus OAR in more detail. Key findings included:
In more recent data from a large American randomized trial, the total health care costs were lower with EVAR.
Device technology, physician experience, and patient selection criteria have improved dramatically since the above studies were initiated. Despite the trade-offs associated with EVAR, it is a viable first line of treatment for anatomically suitable patients.
For patients with severe carotid artery stenosis, the choice between minimally invasive carotid stenting (CAS) versus carotid endarterectomy (CEA) is hotly debated.
In 2006, the French EVA-3S trial found that in patients with symptomatic carotid stenosis of 60% or more, the rates of death and stroke at 1 and 6 months were lower with CEA than with CAS (4). There was a very high risk of stroke when embolic protection devices were not used routinely with carotid stenting. The predominant practice in the United States is to routinely use embolic protection devices.
In 2008, the American SAPPHIRE trial of high risk patients, found no significant difference in long-term outcomes between patients who underwent CAS with an embolic protection device and those who underwent CEA (5).
More recently, the largest trial of all, the American/Canadian CREST study found that among patients with symptomatic or asymptomatic carotid stenosis, primary composite endpoint risk (stroke, myocardial infarction [MI], or death) did not differ significantly between patients undergoing CAS with routine embolic protection versus those undergoing CEA (6). However, there was a higher risk of periprocedural stroke with stenting and a higher risk of periprocedural MI with endarterectomy.
More studies are in progress, and will provide better insight into which patients are best treated with CAS, CEA, and medical therapy alone.
Consultation and More Information
For more information about minimally invasive treatments for vascular disease, or to contact us, click here.