Open surgical repair was the standard method of aneurysm repair for five decades.

Dr. Juan Parodi, Dr. Julio  Palmaz and Dr. Nicholas  Volodos are recognized as pioneers of endovascular aneurysm repair.  Dr. Parodi and Dr. Palmaz performed their first case in September of 1990. Dr. Frank Veith and Dr. Michael Marin and Dr. Parodi performed the first endovascular case in the United States in New York on November 22, 1992.

After years of technological development, endovascular repair of abdominal aortic aneurysms were eventually approved in the United States in September of 1999.  My endovascular team, which was already performing complex vascular cases since the early ’90s, was brought together and was excited about being pioneers. With appropriate treatment planning and strategy, the team was ready.

On December 3^rd, 1999, I brought the endovascular team together including myself, Abercrombie interventional radiologist Dr. Lloyd Smith and my lead surgical technologist Kimberly Hardy and successfully carried out the first endovascular aneurysm repair in East Tennessee.  My involvement in early endovascular aortic techniques and deployments including hybrid techniques allowed me to help teach other colleagues, vascular surgical personnel and participate in multiple new trials and registries. This was the beginning of a new and exciting era.

Endograft used in 1999

The early endovascular aortic stent grafts were larger and not as flexible and could not accommodate some of the anatomic challenges.  The evolution of new technology though has allowed lower profile stent grafts to track easily and treat a wide array of aortic pathology. We can now treat more patients with endovascular techniques than ever before.

Two decades have gone by and we continue to develop and embrace new technology that ultimately saves lives and limbs.

ENDOVASCULAR ANEURYSM REPAIR

The aorta is the largest blood vessel in the body. An aortic aneurysm is a bulging or ballooning of the wall of the abdominal aorta.  As the aneurysm enlarges it stretches the aorta. Abdominal aortic aneurysms can often grow slowly without symptoms, making them difficult to detect. Once detected you should be in an aortic surveillance program watching for potential growth.  Small aneurysms can stay stable and small and never grow. Some small aneurysms never rupture. Some aneurysms grow slowly over time and others expand quickly.

If you have a symptomatic or enlarging abdominal aortic aneurysm, you might notice:

• Deep, constant pain in your abdomen or on the side of your abdomen or back pain

If your aneurysm reaches a critical point the aorta can rupture and can cause life-threatening bleeding. Your vascular surgeon can help you with surveillance and decision making regarding the best treatment option.

Risk factors:  There are multiple risk factors but the most common are listed below

• Tobacco use. Smoking can weaken the aortic walls, increasing the risk not only of developing an aortic aneurysm but of rupture.
• These aneurysms occur most often in people age 65 and older but can also occur in younger patients.
• Men develop abdominal aortic aneurysms much more often than women
• Family history. If anyone in your family had an abdominal aortic aneurysm it increases your risk of having the condition. Please get an ultrasound of your abdominal aorta.
• Other aneurysms. Having an aneurysm in another large blood vessel, such as the artery behind the knee or the aorta in the chest, increases your risk of an abdominal aortic aneurysm.

The current procedure usually takes 2-3 hours through two small groin incisions. It can also be performed under local anesthesia percutaneously without skin incisions if appropriate.  This is certainly much different than two decades ago and patients are usually discharged within one to two days.

Image: https://www.researchgate.net/figure/Ancure-Endograft-bifurcated-graft-with-the-markers-enhanced-Markers-are-sewn-at-regular_fig1_3221520

Image: https://surgery.ucsf.edu/media/1672048/aneurysm_endovascular%20repair.jpg

The post Marking the 20th Anniversary of First Endo AAA Repair first appeared on Premier Surgical.

With peripheral arterial and vascular disease affecting some 8 million Americans, imaging technology to evaluate blood flow and venous function has become an invaluable tool. Imaging methods such as Vascular Ultrasound, Magnetic Resonance Angiography (MRA), and Computed Tomographic (CT) Angiogram are increasingly used to screen, diagnose, and treat vascular issues.

Vascular ultrasound uses sound waves, not radiation, to produce real time images that show the structure and movement of blood flow throughout the body. Doppler ultrasound scans visualize blood flow through blood vessels and major arteries, enabling physicians to identify and pinpoint blockages, blood clots, and abnormalities. Ultrasound also aids physicians in planning effective treatment by assessing the size and condition of blood vessels.

As a non-invasive, inexpensive, and widely available technology, ultrasound has become a primary diagnostic tool. The fact that ultrasound equipment is often portable, and is a safe, painless test, makes it particularly valuable in screening at-risk patients for peripheral arterial, carotid disease, venous insufficiency, aneurysms, and a host of other vascular issues.

The future is bright for ultrasound as new advances in technology allow it to become a three-dimensional tool aiding in the diagnosis of vascular disease.

Despite its benefits, vascular ultrasound does have some limitations. Smaller and deeper vessels can be more difficult to evaluate and image with vascular ultrasound. In some cases, ultrasound cannot differentiate between an occluded blood vessel and one that is significantly narrowed. Calcifications may also obstruct the ultrasound beam. In those cases, other imaging tests such as Magnetic Resonance Angiography (MRA) or CT Angiogram may be necessary.

MRA is a non-invasive test that uses strong magnetic waves to produce detailed images of the vascular system. An MRA can show the location of a blocked blood vessel and the condition of the blood vessel walls. It is especially accurate for larger blood vessels. In some cases, MRA can provide information that can’t be obtained from an ultrasound or CT scan.

During the MRA procedure, the area of the body being imaged is placed inside a MRI machine. The narrow tunnel and long scan times can be problematic for obese patients or those with claustrophobia. Contrast dye may be used to increase visualization of blood vessels. While MRA is a safe and valuable procedure for studying blood vessels, it is more expensive than other imaging methods and may not be available in all medical facilities.

CT angiography is a minimally invasive test that uses x-ray beams to scan the body and produce detailed cross-section images of blood vessels and tissues. In most cases an iodine-rich contrast material is injected and used to highlight the area being studied. For patients with vascular disease, lower extremity CT angiography is especially effective at delivering precise detail in small blood vessels. It is also valuable in the work up and planning therapy of thoracic and abdominal aortic aneurysms.

Many vascular patients can undergo CT angiography instead of a traditional catheter angiogram. This method is quicker and more comfortable for most patients.

The CT angiography is also valuable in screening and detecting the narrowing or obstruction of blood vessels and venous disease before symptoms are present. Limitations include the slight risk of cancer from radiation exposure and possible reaction to the iodine-rich contrast dye.

As imaging technology continues to advance, with improved clarity that includes capabilities such as 3-D visuals, vascular patients will benefit from more accurate screening and diagnostic methods that lead to earlier treatment and better outcomes. The future of imaging is bound to enhance and make the future brighter for vascular patients.
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George A. Pliagas, MD, FACS is a vascular surgeon with Premier Surgical Associates in Knoxville, Tennessee. He serves patient at Tennova Physicians Regional, Tennova North Knoxville Medical Centers, and the Premier Vascular Access & Imaging Center on Papermill Drive.

The post Seeing Vascular Disease More Clearly: The Role of Imaging in Screening & Diagnosis first appeared on Premier Surgical.

The post Another Premier First: New Technology Means Better Outcomes for Thoracic Aortic Aneurysm Patients first appeared on Premier Surgical.