ENDOVASCULAR MANAGEMENT OF VASCULAR DISEASE: CURRENT TECHNOLOGY AND APPLICATIONS

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1 ENDOVASCULAR MANAGEMENT OF VASCULAR DISEASE: CURRENT TECHNOLOGY AND APPLICATIONS Preface Fred A. Weaver and Douglas B. Hood xi Advances in Vascular Imaging 1189 Vincent L. Rowe and Sonny W. Tucker, Jr The improvement of vascular imaging has allowed the acquisition of vascular images with higher resolution while minimizing the risks and discomfort to patients. As imaging developments continue to progress, establishment of valid clinical-based evidence, before the application of each innovation, will assure maintenance of the current trend. Also, as the vascular surgeon adopts a more comprehensive approach in the care of vascular patients, a high-quality endovascular suite will provide an environment for integration of both traditional open and evolving endovascular procedures. Advances in Stent Technology and Drug-Eluting Stents 1203 Nicolas Nelken and Peter A. Schneider From an initially simple concept, vascular stents have evolved into highly specialized instruments, and are poised to develop into sophisticated drug-delivery systems. Although primary research has mostly targeted the coronary circulation, newer generation stents, deliverable almost anywhere, retarding neointimal hyperplasia and thrombosis, and promoting endothelial overgrowth, will offer the next approximation of true vascular healing. This, in turn, promises to promote less invasive, safer, and finally durable endovascular solutions to current surgical problems. Thrombolysis and Mechanical Thrombectomy for Arterial Disease 1237 Zachary C. Schmittling and Kim J. Hodgson Thrombolytic therapy has been around for close to 30 years now, but its exact role in the treatment of acute and chronic arterial VOLUME 84 Æ NUMBER 5 Æ OCTOBER 2004 v

2 occlusive disease continues to be debated. Studies have produced varying and contradictory results. We are still not sure if thrombolysis has any true advantages over surgical thromboembolectomy, or which lytic agent is the best. Nonetheless, the technique still plays an important role in the treatment of arterial occlusions. The Use of Closure Devices 1267 Steven G. Katz and Alan Abando The use of arterial closure devices offers significant benefits over manual compression in achieving groin hemostasis following catheter-based procedures. Several currently available devices provide rapid puncture site closure with complication rates similar to that of manual compression. Closure devices allow for early times to ambulation and hospital discharge, and have a high degree of patient satisfaction. Their use may be of particular benefit inpatients that are anticoagulated. We believe that their use should be strongly considered in all patients following femoral artery catheterization. Carotid Artery Stenting 1281 Robert W. Hobson II Efficacy for carotid artery stenting (CAS) has not been confirmed by randomized clinical trial methodology in conventional risk patients. Although carotid endarterectomy (CEA) is considered the preferred method for carotid revascularization in the management of patients with symptomatic and asymptomatic extracranial carotid occlusive disease, comparisons between CAS and CEA are now underway. In North America, the CREST (Carotid Revascularization Endarterectomy versus Stent Trial) protocol is now completing its lead-in or credentialing phase as randomization of cases is initiated. In Europe, the CAVATAS (Carotid and Vertebral Artery Transluminal Angioplasty Study) and Stent Protected Angioplasty versus Carotid Endarterectomy trials are recruiting symptomatic patients for randomization between CEA and CAS. It is anticipated that these trials will publish definitive results within the next 1 to 3 years, and help guide the referral of patients for CAS and CEA in the future. Current Status of Thoracic Aortic Endograft Repair 1295 Jason T. Lee and Rodney A. White The advent and success of endovascular repair of abdominal aneurysms had led to the development of catheter-based techniques to treat thoracic aortic pathology. Such diseases, including thoracic aortic aneurysms, acute and chronic type B dissections, penetrating aortic ulcers, and traumatic aortic transection, challenge surgeons to perform complex operative repairs in high-risk patients. The minimally invasive nature of thoracic endografting may provide an attractive alternative therapy especially in patients vi

3 deemed unfit for thoracotomy. A worldwide review of thoracic endografting demonstrates encouraging short- and midterm outcomes with significant reductions in morbidity and early mortality. Long-term surveillance will be crucial to discover complications unique to thoracic endovascular interventions and to determine which patients are appropriate candidates for stent-graft therapy. Suprarenal Stents and Other Advances in Endovascular Aneurysm Repair 1319 Timothy A.M. Chuter and Benjamin A. Howell The history of endovascular aneurysm repair has already passed through its phases of endoexuberance and endoscepticism and there is now a balanced and broad understanding of the technology, its limits and advantages. Current endovascular technique and stent-graft design is the refinement of the accumulated endovascular experience til now. It is important to make note of these technological features incorporated in current stent grafts and the clinical experience that precipitated their introduction as the technology progresses and new applications are proposed. What is the Significance of Endoleaks and Endotension 1337 Maarit A. Heikkinen, Frank R. Arko, and Christopher K. Zarins Endovascular repair has been used over a decade as a treatment of abdominal aortic aneurysm, and has become a widely accepted treatment method with a low rate of perioperative complications. Endoleak, perigraft blood flow outside endograft but within aneurysm sac, has been intensively studied during the last 10 years of endovascular aneurysm repair (EVR). The natural history of aneurysms with endoleak and the true clinical significance of various types of endoleaks remains unclear. Type I/III endoleak has been found to be associated with aneurysm rupture, while the risk of rupture of aneurysms with type II endoleak and endotension appears very small. In endotension, the aneurysm sac remains pressurized, even if there is no evidence of an endoleak. Currently, it is accepted that type I/III endoleaks should be corrected, preferably by endovascular means, due to the risk of rupture. If endovascular repair is not possible, then open conversion should be considered. The risk of conversion should be weighed against the risk of aneurysm rupture. Treatment of type II endoleaks and endotension is more controversial. In those with aneurysm enlargement, secondary interventions are often performed. Current Endovascular Management of Atherosclerotic Renal Artery Stenosis 1353 Rajeev K. Rao, Douglas B. Hood, and Fred A. Weaver The recent advances in stent technology and renal endovascular management have provided a technically reproducible method of vii

4 percutaneously treating atherosclerotic renal artery stenosis (RAS). In many centers, this has resulted in endovascular management being the primary therapy for atherosclerotic RAS. Although still controversial, it appears that endovascular management of RAS by primay stent deployment provides better blood pressure control than that afforded by best medical management. The impact on renal function is less than that found for hypertension, but there is evidence to suggest that the use of protection devices and primary stenting may enhance renal function outcomes. Whether the ultimate benefit of enhanced survival follows remains an important question and should be the subject of future prospective studies. Subintimal Angioplasty for Infrainquinal Occlusive Disease 1365 Gerald S. Treiman Subintimal angioplasty is a relatively new endovascular approach for the treatment of patients with femoropoliteal or tibial artery occlusion. The procedure involves intentionally creating a false channel or dissection around an arterial occlusion, then reentering the true lumen distally. The procedure has a relatively low incidence of complications and a high rate of technical success. Short-term patency has been fair in some reports and poor in others. Long-term results are not available. Aspirin and possibly anticoagulation or antiplatelet agents may improve technical success and short-term patency. Further studies with longer follow-up are required before it can be recommended as a potentially viable alternative to arterial bypass. Endovascular Management of Iliofemoral Venous Occlusive Disease 1381 Douglas B. Hood and Jason Q. Alexander New developments in the management of both acute and chronic iliac vein occlusive disease offer exciting options for the treatment of this often debilitating condition. Percutaneous clot removal using thrombolysis, mechanical thrombectomy, or a combination of the two is fast becoming the treatment of choice for patients presenting with acute iliofemoral deep vein thrombosis. Recanalization of chronic iliac vein occlusions with balloon angioplasty and stenting relieves symptoms of extremity swelling and pain in the majority of treated patients. Existing data provide convincing proof of the efficacy of endovascular recanalization procedures, and upcoming prospective, controlled trials will further clarify the role of these techniques in the therapeutic armamentarium. New Approaches for the Treatment of Varicose Veins 1397 Theodore H. Teruya and Jeffrey L. Ballard New, minimally invasive techniques for the treatment of varicose veins including radiofrequency ablation (RFA), endovenous laser viii

5 therapy (EVLT), and transilluminated power phlebectomy (TIPP) represent effective and possibly superior alternatives to traditional saphenous vein stripping and stab avulsion of varicose veins. Further experience with these procedures will help to determine which ones will become the method of choice for treating this complex disease process. Some of these new techniques may not prove to be effective in the hands of all treating specialists. However, it is very likely that some of these techniques, such as foam sclerotherapy and RFA, will replace the procedures that we currently use today. Index 1419 Subscription Information ix