11/10/2017 Open Vascular Surgery Still Relevant in 2017? u Carotid Endarterectomy vs Stenting? u Aortic Endografts vs Grafting? u Mesenteric Stents vs Reconstruction? u Saphenous Stripping vs RFA? Carotid Endarterectomy u Millions of cases performed u Extensive experience by individual physicians u Hundreds—if not thousands—of published studies u Well defined outcomes, long and short term u Well defined costs and optimal approach 1 11/10/2017 FDC/Cox Carotid Experience Reviewed single surgeon carotid endarterctomies at Cox, 1998-2005: 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 Final data collection Endarts ongoing Thus far, no change in outcomes CEA Outcomes…. u FDC/Cox “all comers” outcomes better than national average--- u ---and better than national studies with selected surgeons u Many studies from good centers with stroke rate of 1-2% u NASCET 6.5% (symptomatic patients) u ACAS 3% (asymptomatic) u Medicare 3.8% (asymptomatic) 2 11/10/2017 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? u Randomized Trial of Stent versus Surgery for Asymptomatic Carotid Stenosis u 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 * u N Engl J Med 2016 ; 374:1011-1020 March 17, 2016 DOI: 10.1056/NEJMoa1515706 “At 1 year, the event rate was 3.8% in the stenting group and 3.4% in the endarterectomy group (stroke, death and MI)” Stenting? 30-day rate of death or any stroke of 2.9% in the stenting group and 1.7% in the endarterectomy group 3 11/10/2017 CEA vs Stenting? u In the end, you’re 60% more likely to have a stroke or die with a stent vs an endarterectomy…. u At what point is that equipoise? u Clinical outcomes and cost comparison of carotid artery angioplasty with stenting versus carotid endarterectomy u Journal of Vascular Surgery u Volume 44, Issue 2 , August 2006, Pages 270-276 u Presented at the Society for Clinical Vascular Surgery meeting, Las Vegas, Nevada, March 8, 2006. u B. Park, MD, A. Mavanur, MD, M. Dahn, MD, , Results Clinical outcomes and cost comparison of carotid artery angioplasty ... www.sciencedirect.com/science/article/pii/S0741521406007877 Carotid endarterectomy Angioplasty and stenting Variable group (n = 48) group (n = 46) Total costs $12,112.28 $17,402.40 Direct costs $7227.18 $10,522.56 Indirect costs $4884.98 $6879.84 4 11/10/2017 What Do We Do? u CEA: Asymptomatic and Symptomatic Stenoses…. u Unless: --Recurrent Stenosis --s/p Radiation/Radical Surgery --Symptomatic Lesion with (truly) Prohibitive Surgical Risk Abdominal Aortic Aneurysms u First Open Repair: Dubost in Paris, 1951 u Extraperitoneal thoracoabdominal approach with aorta harvested 3 weeks previously from a 20yo female trauma patient u Approached through the 11 th rib Abdominal Aortic Aneurysms u First Aortic Endograft: Parodi, 1991 u Approved in USA: 1999 u Now used for ?> 80% of infrarenal aneurysms u Not all aortic aneurysms are infrarenal! 5 11/10/2017 AAA: Not All Are Simple…. AAA: Some Are More Complex…. AAA: Or Even More Complex… 6 11/10/2017 For Most Patients: Mesenteric Artery Stenting u Renal Artery Stents: Now Rare!! u Reserved for Single Kidneys or Bilateral Lesions u Day of the Drive By Stent is Dead (and good riddance!) Visceral Artery Stents? u Celiac Artery Stents: Very Rarely Indicated u SMA Stents: One of the Rare Indications for a “Prophylactic Stenting” in Vascular Disease 7 11/10/2017 SMA Surgery Exposure? Incision? 8 11/10/2017 Outcomes: Open Surgery vs Stenting u Int Angiol. 2009 Apr;28(2):132-7. u Clinical outcomes of mesenteric artery stenting versus surgical revascularization in chronic mesenteric ischemia. u Kougias P1, Huynh TT , Lin PH . u 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 three- year 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). u CONCLUSIONS: u Endovascular treatment offers shorter hospitalization… (with) similar morbidity and mortality rates. Surgical reconstruction…gave long-term symptomatic relief compared to endovascular cohorts. Mesenteric Reconstruction u Science on the side of open reconstruction u Patients on the side of interventions u Patients win (for now) Historically: Saphenous Vein Stripping More Recently: Radio Varicose Vein Frequency Ablation Therapy Is It Progress? 9 11/10/2017 Long Term Outcomes? u Stripping: 100% (never recanalizes) u RFA: 97% (sometimes recanalizes) Procedure: Stripping vs RFA u Stripping: GETA/OR + Hospitalization + ?? u RFA: Outpatient, under local, ~30 minutes DVT <1% RFA Skin Burns: <<1% Complications? Nerve Injury: <1% 10 11/10/2017 Stripping Complications? u Hematoma ~5% u Nerve Injury 35% u DVT ~1% u Risks of GETA, Hospitalization u Pain! Cost? u Stripping: GETA + Hospital + Surgeon u RFA: Surgeon + Outpatient u Roughly 4X difference: RFA v Stripping Not Surprisingly….. u Only 1 patient in >10 years has insisted on stripping over RFA 11 11/10/2017 In Summary… u Carotid Stenosis: CEA for “all”!! u Aortic Aneurysm: Endografts for 85% u Visceral Vessels: Stents for 90% u Varicose Veins: RFA for “all”!! 12.