Endovascular

Only do what your heart tells you - Princess Diana

Endovascular

image by: Ezgu Niyat‎Врачи Узбекистана
     

 

It does not take a soothsayer to realize that more and more vascular lesions will become amenable to endovascular treatment. By 2026, one can predict that 75% to 95% of all vascular lesions requiring treatment will undergo an endovascular procedure. With the creativity of vascular surgeons and others, this percentage will likely increase. Moreover, all of these treatments will be deliverable via percutaneous approaches.

Does this increasing role for endovascular treatments mean that the day of open surgery is over? Definitely not. There will always be a need for hybrid (open + endovascular) repairs in ∼5% of vascular lesions. Cervical approaches to the carotid artery, the need for conduit access, and some open treatments after EVAR are three examples. Also, there will always be a need for fully open surgery in ∼5% to 15% of patients requiring invasive treatment, although some of these procedures may be improved by endovascular adjuncts. Open surgical treatment will always be best in some patients with the conditions and lesions I have already mentioned, although the numbers and proportions of these lesions will decrease as improved endovascular technology and techniques are developed and are proven superior.

How should vascular surgery deal with the decreasing numbers of complex open procedures and who should do them? One solution is to have centers to which these patients are sent and in which vascular surgeons seeking this skill can get adequate open training.

Other thoughts about the future

Seminal advances in vascular surgery have always been made possible by advances in other fields, most importantly pharmaceuticals and technology. Heparin, safe contrast agents, and prosthetic vascular grafts are three prominent examples. Similarly, the explosive progress in endovascular treatments was made possible by improvements in digital imaging and the catheter-based technology our industry partners provided.

In like fashion, future advances in vascular surgery and vascular disease treatment will depend on advances in other fields. On the horizon are better medical treatments to arrest and even reverse atherosclerosis. Statin drugs are just the beginning and have already decreased rates of heart attacks, strokes, and death. Better use of these drugs will make them more effective, improve our treatments, and help our patients have longer and better lives. Despite this and the possibility of even more effective lipid-lowering with proprotein convertase subtilisin/kexin type 9 (PCSK 9) inhibitors, complications of atherosclerosis will still occur and require our interventions, probably in increasing numbers as our population ages. This ensures a continuing need for the services vascular surgeons provide.

Also brightening the future of vascular surgery and our patients will be advances in the technology that will improve our treatments. This is particularly true with endovascular procedures because of their need for guidance within the vascular system. Glimpses of computer-assisted three-dimensional device navigational tools are already appearing. So also are systems analogous to global positioning within the vascular tree. Radiation will not be required, thereby decreasing hazards to patients and operators. Advances in robotic guidance will also decrease radiation exposure and facilitate device placement. Computer-enhanced simulation will improve training and, when patient specific, will allow procedure planning and rehearsal, thereby improving patient outcomes. Three-dimensional printed models of lesions and blood vessels will contribute to these improvements.

Patient outcomes and the durability of endovascular treatments will also improve with better stent technology. This includes advances in bioresorbable and drug-eluting stents. Similarly, the already promising results of drug-coated balloons will be enhanced. All these devices are complicated with many variable factors. The bottom line is that intimal hyperplasia will be overcome by antiproliferative drugs in all vascular beds once the best way of getting the best drug to the proper location is found. And finally, computer-enabled remote monitoring of flows within grafts and stents will allow corrective treatment before occlusion occurs. Miniaturized piezoelectric sensors are one way to do this.

All these promising new vascular devices and treatments need validation. Their value and cost effectiveness will have to be documented. This will create enormous research opportunities for all academically ambitious vascular surgeons.

So the future for vascular surgery, vascular surgeons, and their patients is bright. There will be exciting new treatments, good research opportunities, and lots of patients needing our attention. However, there are some challenges that vascular surgery must face. How well the specialty deals with these challenges will affect the brightness of its future.

Source: Frank Veith MD, Excerpt from A look at the future of vascular surgery, Journal of Vascular Surgery, October 2016, Volume 64, Issue 4, Pages 885–890.

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Last Updated : Sunday, December 6, 2020