Open Vascular Surgery

Transcription

1 Open Vascular Surgery Still Relevant in 2017? Carotid Endarterectomy vs Stenting? Aortic Endografts vs Grafting? Mesenteric Stents vs Reconstruction? Saphenous Stripping vs RFA? Carotid Endarterectomy Millions of cases performed Extensive experience by individual physicians Hundreds if not thousands of published studies Well defined outcomes, long and short term Well defined costs and optimal approach 1

2 FDC/Cox Carotid Experience Reviewed single surgeon carotid endarterctomies at Cox, : Mortality rate of 0.01% Stroke rate of 0.5% Length of stay 1.8 days Long term patency >95% Recurrent stenosis rate of <5% Reviewing multiple surgeon outcomes, 2005 to present Carotid Endarts Final data collection ongoing Thus far, no change in outcomes CEA Outcomes. FDC/Cox all comers outcomes better than national average and better than national studies with selected surgeons Many studies from good centers with stroke rate of 1-2% NASCET 6.5% (symptomatic patients) ACAS 3% (asymptomatic) Medicare 3.8% (asymptomatic) 2

3 Stenting? Multiple studies suggesting clinical equipoise for CEA and CAS Significant debate between professional societies as to indications and preferability for CEA vs CAS The SVS represents the only group of physicians who perform both procedures Who is right? Stenting? Randomized Trial of Stent versus Surgery for Asymptomatic Carotid Stenosis Kenneth Rosenfield, M.D., M.H.C.D.S., Jon S. Matsumura, M.D., Seemant Chaturvedi, M.D., Tom Riles, M.D., Gary M. Ansel, M.D., D. Chris Metzger, M.D., Lawrence Wechsler, M.D., Michael R. Jaff, D.O., and William Gray, M.D., for the ACT I Investigators * N Engl J Med 2016; 374: March 17, 2016DOI: /NEJMoa Stenting? At 1 year, the event rate was 3.8% in the stenting group and 3.4% in the endarterectomy group (stroke, death and MI) 30-day rate of death or any stroke of 2.9% in the stenting group and 1.7% in the endarterectomy group 3

4 CEA vs Stenting? In the end, you re 60% more likely to have a stroke or die with a stent vs an endarterectomy. At what point is that equipoise? Clinical outcomes and cost comparison of carotid artery angioplasty with stenting versus carotid endarterectomy Journal of Vascular Surgery Volume 44, Issue 2, August 2006, Pages Presented at the Society for Clinical Vascular Surgery meeting, Las Vegas, Nevada, March 8, B. Park, MD, A. Mavanur, MD, M. Dahn, MD,, Clinical outcomes and cost comparison of carotid artery angioplasty... Variable Carotid endarterectomy group (n = 48) Angioplasty and stenting group (n = 46) Total costs $12, $17, Direct costs $ $10, Indirect costs $ $

5 What Do We Do? CEA: Asymptomatic and Symptomatic Stenoses. Unless: --Recurrent Stenosis --s/p Radiation/Radical Surgery --Symptomatic Lesion with (truly) Prohibitive Surgical Risk Abdominal Aortic Aneurysms First Open Repair: Dubost in Paris, 1951 Extraperitoneal thoracoabdominal approach with aorta harvested 3 weeks previously from a 20yo female trauma patient Approached through the 11 th rib Abdominal Aortic Aneurysms First Aortic Endograft: Parodi, 1991 Approved in USA: 1999 Now used for?> 80% of infrarenal aneurysms Not all aortic aneurysms are infrarenal! 5

6 AAA: Not All Are Simple. AAA: Some Are More Complex. AAA: Or Even More Complex 6

7 For Most Patients: Mesenteric Artery Stenting Renal Artery Stents: Now Rare!! Reserved for Single Kidneys or Bilateral Lesions Day of the Drive By Stent is Dead (and good riddance!) Visceral Artery Stents? Celiac Artery Stents: Very Rarely Indicated SMA Stents: One of the Rare Indications for a Prophylactic Stenting in Vascular Disease 7

8 SMA Surgery Exposure? Incision? 8

9 Outcomes: Open Surgery vs Stenting Int Angiol Apr;28(2): Clinical outcomes of mesenteric artery stenting versus surgical revascularization in chronic mesenteric ischemia. Kougias P 1, Huynh TT, Lin PH. Endovascular treatment in 48 patients (58 vessels), open repair in 96 patients (157 vessels). Operative strategies included bypass grafting (N.=72, 75%); transaortic endarterectomy (N.=19, 20%), or patch angioplasty (N.=5, 5%). length of stay was 3 vs 12 days. No difference in 30-day mortality, in-hospital complication, or threeyear survival rate. Freedom from recurrent symptoms at three years were significantly greater in the open group (66%) compared to the endovascular group (27%, P<0.02). CONCLUSIONS: Endovascular treatment offers shorter hospitalization (with) similar morbidity and mortality rates. Surgical reconstruction gave long-term symptomatic relief compared to endovascular cohorts. Mesenteric Reconstruction Science on the side of open reconstruction Patients on the side of interventions Patients win (for now) Historically: Saphenous Vein Stripping Varicose Vein Therapy More Recently: Radio Frequency Ablation Is It Progress? 9

10 Long Term Outcomes? Stripping: 100% (never recanalizes) RFA: 97% (sometimes recanalizes) Procedure: Stripping vs RFA Stripping: GETA/OR + Hospitalization +?? RFA: Outpatient, under local, ~30 minutes DVT <1% RFA Complications? Skin Burns: <<1% Nerve Injury: <1% 10

11 Hematoma ~5% Stripping Complications? Nerve Injury 35% DVT ~1% Risks of GETA, Hospitalization Pain! Cost? Stripping: GETA + Hospital + Surgeon RFA: Surgeon + Outpatient Roughly 4X difference: RFA v Stripping Not Surprisingly.. Only 1 patient in >10 years has insisted on stripping over RFA 11

12 In Summary Carotid Stenosis: CEA for all!! Aortic Aneurysm: Endografts for 85% Visceral Vessels: Stents for 90% Varicose Veins: RFA for all!! 12