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Physicians Update

 
Fall 2010

From Surgery to Interventional Radiology to Cardiology, Treatment Options for Vascular Disease Expand

PU Fall 2010-Aneurysm SurgeryTreatment options for vascular disease have expanded significantly in the last two decades. UCLA now offers a host of state-of-the-art therapies delivered by vascular surgeons, interventional radiologists and cardiologists, including endovascular repair for aneurysms and ischemic vascular disease.

Aneurysms are defined as arteries that bulge to one and a half times the size of the vessel on either side. But many aneurysms will remain for long periods of time without rupturing or developing clots that embolize. “When we see an aneurysm, we have to make a judgment as to when to fix it,” says Peter F. Lawrence, M.D., chief of vascular surgery and director of the Gonda (Goldschmied) Vascular Center.

The decision depends to a great extent on location. In the aorta, for example, repair is typically delayed until the aneurysm reaches two to three times normal size. Aneurysmal repair was once done entirely through open surgery in which artificial material was sewn in to replace the blood vessel. In 1993, two UCLA vascular surgeons, Wesley Moore, M.D., and William Quinones, M.D., placed the first Food and Drug Administration-approved endograft in the United States; in the 17 years since, millions have been done throughout the world.

Endovascular repair with endografts involves insertion of covered stents of Dacron or Teflon through a small groin skin puncture or incision and guided through the femoral arteries to their proper location. The technology has been refined to the extent that it can now be used with a much wider variety of patient anatomies than in the past. “Instead of a major operation, it’s a quick recovery with a much lower mortality from the procedure — less than a 1 percent risk,” Dr. Lawrence says.

At least two-thirds of patients who previously would have required open surgery to repair their aneurysm are instead receiving endovascular repair, notes Stephen T. Kee, M.D., chief of interventional radiology at UCLA. “The recovery period is significantly less — a day or two as opposed to a number of weeks.”

UCLA is at the forefront of a new endovascular approach, using endografts for patients with aneurysms located near large branches — in the arteries to the kidneys, the intestine and the liver. “In the past, those all had to be done with a big operation, but now we can build an endograft to repair the aorta from the inside,” Dr. Lawrence explains. This occurs through a hybrid approach that combines open surgery with endovascular repair. And, recently, a “fenestrated” endograft has been developed, in which the vascular surgeons place the “trunk” of the graft into the aorta, cutting small holes in the side and sending branches out to the critical arteries.

The new procedure further extends the reach of aneurysmal treatment through the less invasive approach. “For 20 years, we’ve been able to do endovascular repair from the arteries to the kidneys down,” Dr. Lawrence notes. “More recently, we learned to do repairs in the thoracic aorta. Now we are able to extend into the arch of the aorta so that we don’t have to do as many big, open operations that involve heart bypass. In the near future, we will be able to replace the aorta from the heart down to the groin.”

Ischemic Vascular Disease. For patients with ischemic vascular disease, percutaneous endovascular repair has increasingly replaced surgical bypass. Ischemic vascular disease can affect a number of areas in the body, including the kidneys through hypertension and the lower extremities through claudication — the development of muscle pain and fatigue in the legs and, in the worst cases, potential limb loss. But as with the treatment of aneurysmal disease, ischemic treatment has benefited from the use of small covered stents. The devices have become much smaller, minimizing discomfort and reducing the potential for cPU Fall 2010-Aneurysm endographomplications at the puncture site, says Dr. Kee. Patients who once would have required a prolonged hospital stay are now generally treated on an outpatient basis with percutaneous repair through a small groin puncture.

Within the next year, the first drug-eluting stents are expected to become available. The technology, now pending FDA approval, is designed to prevent restenosis. These stents have been available for use in the heart for several years but have only recently been shown to be effective in treating peripheral vascular disease in the lower extremities.

“Stents with drug-eluting properties have been a major advance for the coronary arteries and are now making a big difference in some patients with peripheral vascular disease,” says James N. Weiss, M.D., chief of cardiology at UCLA.

For ischemic patients at risk of losing a limb, revascularization — getting more blood supply down to the leg — is critical, but represents only part of the treatment, Dr. Lawrence says. Equally important are factors ranging from optimal wound care to proper management of the underlying cause of the ischemia, which in a growing number of cases is diabetes. Care for these patients should address the big picture through a multidisciplinary approach.

“As we see more and more people with diabetes, we need to be managing their wounds much more aggressively to prevent them from losing their legs,” he asserts. “We can save nearly every patient with ulcers and gangrene of the extremities if we get the patient early enough.” This is critical not just as a quality-of-life issue; Dr. Lawrence notes that patients who lose a leg from peripheral vascular disease have about a 50 percent chance of losing the other leg within a two to three year period, and their mortality risk increases substantially.





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