Endovascular Surgery: A Doctor's Perspective
In June 2003, Satish Muluk, M.D. a noted vascular surgeon and critical care specialist, joined the Department of Cardiothroacic Surgery at Allegheny General Hospital and was named Director of the Division of Vascular Surgery. Dr. Muluk explains what endo-vascular surgery is and how he has approached treating patients who require Bloodless Surgery.
“For more than 10 years, I have had the privilege of treating a large number of vascular surgery patients in western Pennsylvania. The problems have included aortic aneurysms, arterial blockages in the legs, blockages of the carotid arteries (vessels supplying blood to the brain), and vascular access surgery for patients needing hemodialysis. During that time, I have seen dramatic changes in almost every aspect of the care of these patients. Overall, we are able to treat the same problems with smaller incisions, faster surgery, shorter hospital stays and decreased blood loss.
A key aspect of the shift has been the increased use of endovascular surgery. Simply put, endovascular surgery is a minimally invasive approach to vascular pathology. Vascular lesions are treated by introducing balloons, stents and grafts from a remote location (usually the groin). Endovascular treatment replaces a direct surgical approach to the lesion. Because a direct approach often requires a long incision and/or enty into a major body cavity such as the abdomen, this shift in approach generally means that endovascular surgery requires a smaller incision, shorter hospital stay and reduced patient risk.
Endovascular intervention has long been an established method of therapy for cardiologists and interventional radiologists. Balloon dilation and stent treatment of iliac and renal stenosis have become the standard of care for many lesions, replacing open surgery in many cases. What is novel about the current wave of endovascular interventions is their more complex and ambitious nature (such as repair of aortic aneurysms). These newer treatments involve:
- The need for general or regional anesthesia
- The need for surgical exposure of the vessel at the site of device entry in order to introduce the endovascular devices (these are typically much larger than devices used in the radiology suite)
- The need to be able to directly expose the site of pathology in case of failure of the endovascular procedure
For these reasons, the newer wave of endovascular interventions qualify as endovascular surgery.
A good analogy for endovascular surgery is laparoscopic surgery (best exemplified by laparoscopic gallbladder removal). In the span of just 3-4 years in the 1980s, laparoscopic gallbladder surgery became the standard of care. It became clear that patients, providers and payers have a strong preference for less invasive and less costly modes of treatment. Endovascular surgery has had a similar impact on vascular surgical practice.
The greatest impact of endovascular surgery has been in connection with aortic aneurysm repair. Reduced blood loss is one of the key benefits. Blood loss for typical open aneurysm repair is 500-700 cc, as compared to 100-150 cc for endovascular repair. As a result, transfusion of blood products is almost never needed for endovascular repair, but it is needed in 30% of open aneurysm cases. This issue is particularly relevant for patients with religious prohibitions against receiving blood products, such as Jehovah’s Witnesses. I have performed open aneurysm surgery for such patients, using techniques such as hemodilution, cell salvaging and autotransfusion (for those patients whose beliefs permit). However, whenever technically feasible, I prefer to offer endovascular repair for patients who are Jehovah’s Witnesses that need aneurysm repair.”
