Monday, April 12, 2010


About a month ago, I refered a friend of mine for surgical resection of an aortic aneurysm. Since then I have been pondering whether I had done the right thing. Should he have gone for an endovascular stent.
I must say that my referal was somewhat biased by the fact that EVAR I ( EVAR stands for Endovascular Aneuysm Repair- a study led by Dr Juan Parodi, the inventor of the endovascular stent ), a trial whose results were released in 2009, showed no difference in longterm survival between an endovascular approach and open surgery ( aneurysm resection and grafting ), although there was higher operative risk. I was also aware that the endovascular stents ( first generation stents ) were not so good and there were significant post stenting complications, including geographical miss and migration of stents after implantation, etc. The training program for endovascular interventionist seemed to be somewhat less stringent then that of coronary interventionist. I can only imagine that the latest endovascular stents must be much improved by now. One day I had the opportunity of observing one of thelocal, senior endovascualr interventionist doing a stent graft. His case was just before mine. I could see him struggling and trying to force a stent graft in position. The whole abdomen seemed to shake as he tugged and pulled to position the stent. I told myself that it was all so crude. Vascular interventions was not suppose to be like this. Soon after that, I was sitting as a moderator in another live demo course and the senior Japanese vascular surgeon was trying to insert two stent into the thoracic aorta. It was also so crudely done with pulling and tugging. One always wonder what happens to all the branches coming off the aorta, during all these forceful movements.
I felt that a standard, simple aneurysm resection ( this friend was in the mid fifties with hypertension as the only co-morbidity ) should do very well with a surgical resection. The aneurysm measured 5 cm in diameter and was infra renal.
Lately, we have also seen the release of the EVAR II results, which also showed an increase vascular mortality in the non-intervention group, although the overall all cause mortality were the same as many died from cancers. The EVAR II was a trial to compare the use of the endovascular stent against non-intervention, in a group of patients with aortic aneurysms who were too sick for surgery.
I will have to keep a closer watch on the endovascular work. I do not do them myself as I believe that I am a cardiac interventionist and should not venture to intervene in all organs of the body, although I am quite sure that I can.

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