Endovascular Abdominal Aortic Aneurysm repair
Varicose Veins
Lower Extremity Angioplasty
Carotid Stenting
Renal (kidney) Artery Stenting
Vena Caval Interruption
Dialysis Access Thrombectomy

Minimally invasive techniques have revolutionized the specialty of Vascular Surgery. Until the last decade only a handful of vascular surgeons had experience with endovascular techniques. Vascular Surgery Associates (VSA) were among the first surgeons in the western United States to use minimally invasive techniques to treat varicose veins and to be given access to FDA-approved endovascular grafts for treatment of abdominal aortic aneurysms. A broad spectrum of endovascular procedures is provided by VSA.

Endovascular Aneurysm Repair (EVAR)
Endovascular graft replacement of abdominal aortic aneurysms (AAA) requires precise imaging and careful planning. Specialized CT scans are sent electronically to Medical Metrx Solutions in New Hampshire for computerized reformatting. Complete evaluation can take 1-2 weeks.

 

 

 

 

 

Based on this imaging, 70% of the AAAs that we evaluate are treated with minimally invasive technology. There are certain anatomic features that prevent EVAR use in all patients. Because of the uncertain long-term outcomes of EVAR we tend to prefer open repair in relatively young (<70 years old), healthy patients. The stent-reinforced grafts are usually placed through the femoral arteries in the groin and positioned inside the aorta. The grafts are placed into the aorta below the arteries to the kidneys and into the arteries going to each leg. Most patients are sent to a regular hospital bed after surgery and go home the following day.

The primary advantage of EVAR is a significantly shorter recovery after surgery, compared to standard open aneurysm repair. Most patients have minimal discomfort and are able to resume normal activity within 2-3 weeks. Follow-up CT scans are required for all patients for the remainder of their lives. 25-30% of patients will require some additional endovascular procedure to stop persistent flow of blood inbetween the graft and the wall of the aorta, known as an endoleak.

Varicose Veins
Treatment of venous disease is individualized to the patient's anatomy and the extent of the problem. Small spider veins can be treated with either laser or sclerotherapy. Larger veins may be removed through tiny incisions, known as microvascular or stab-avulsion technique. If the main superficial, or saphenous, vein is not functioning properly this is usually treated with a relatively new technique, radiofrequency ablation. This procedure is less invasive than traditional ligation and stripping and allows return to normal activity within days. For further information about treatment of venous disease, see related page.

Lower Extremity Angioplasty
The two reasons that we intervene to improve the blood supply to the legs is for walking pains and to prevent an amputation. Pain with walking can be due to a number of causes - circulation and arthritis of the spine are the two most common. If it is determined that walking pain, or intermittent claudication, is due to arterial blockages your vascular surgeon can help you decide whether the risk of treatment is warranted. In the past bypass surgery was the only option. Now angioplasty has replaced surgery for many patients with intermittent claudication. The results of angioplasty, or ballooning, of the artery are dependent on the location and the length of the blockage. Angioplasty of the iliac arteries (above the groin) has nearly the same success as surgery, if the blockage is localized. Angioplasties below the groin have about a 50% rate of success one year after the procedure. Drug-coated stents, which are not currently available, may improve these results in the future.

Patients who are at risk for losing their legs because of poor circulation and non-healing wounds of the feet frequently have multiple, long blockages. Occasionally an angioplasty alone may be sufficient to heal a wound. The physicians of Vascular Surgery Associates can provide the broad spectrum of open or endovascular therapy depending on the needs of the patient.

Carotid Stenting
Large scientific studies have established the effectiveness of carotid artery surgery in reducing the risk of stroke over time. In most cases patients are best treated with open surgery to remove the buildup of calcium, cholesterol, and cells that can come loose and travel to the brain. The stroke rate within 30 days of surgery has been 0.3% (or 1 in 300) in our last 1700 carotid endarterectomies. These results are better than published standards for the procedure.

Carotid stenting is a relatively new procedure that may be equal to surgery in certain high-risk patients, such as those with severe heart or lung disease, or patients with recurrent narrowing after prior surgery. Before consideration of a stent placement, patients should have an angiogram to determine the suitability of their anatomy. We have performed carotid stenting on a limited basis when surgery appeared to carry greater risk than usual. The stroke rates reported from large series range from 2-10%. New devices are rapidly becoming available which may significantly reduce the risk of the percutaneous procedure and expand the use of carotid stenting. A specialist with excellent results with both procedures should make the decision regarding stenting versus surgery.

Renal Artery Angioplasty
Blockage of the circulation to the kidneys is usually caused by atherosclerosis, or hardening of the arteries. In rare cases, primarily in women, a disease called fibromuscular dysplasia can cause a thickening of one of the layers of the artery wall. Either one of the conditions can reduce the blood supply to the kidneys causing high blood pressure that is difficult to control. If the blockage affects both kidneys the function can deteriorate and renal failure may follow. The best method to diagnose this blockage is a noninvasive study, an MR angiogram. If there is evidence of significant blockage, a renal artery angioplasty is the usually best form of treatment. The results from angioplasty are nearly as good as surgery and certainly far less invasive. Renal artery surgery is occasionally necessary when the disease is associated with aneurysm of the artery or simultaneous surgery on the aorta is contemplated.

Vena Caval Interruption
The usual treatment of clots in the deep veins of the legs is anticoagulation ("thinning of the blood"). This substantially reduces the risk of clots traveling to the lungs, an event that can be fatal. Some patients either cannot be put on anticoagulation because of the risk of bleeding or have had clots travel while on appropriate doses of medicine. In this situation a filter is inserted through a small puncture in a vein in the groin and is placed into the main vein in the abdomen, the vena cava, under X-ray guidance. This filters the blood coming from both legs. In some patients a temporary filter can be placed that can be removed when the risk of clots has sufficiently declined. The filter can be removed through a small puncture under local anesthesia, similar to placement of the original device.

Dialysis Access Thrombectomy
Artificial grafts are frequently placed in the arms and legs to provide access to the circulation for hemodialysis. These grafts frequently develop narrowing where they are sewn into the vein. When these graft clot, patients cannot have their usual dialysis. In most cases, the graft can be reopened without surgery using a device placed directly into the graft through a needle stick. After removing the clot, an angiogram can reveal areas of narrowing that can be dilated with a balloon. If clotting occurs frequently or a severe narrowing is found that does not respond well to angioplasty, open, surgical repair of the graft may be required.