(Endo)vascular worries

How best to treat vascular disease? For Dr. Alik Farber of Boston Medical Center, endovascular surgery is one “exciting” option. And there are more. What worries him is that not many people seem to know what vascular surgeons do.

Endovascular surgery is a relatively new, minimally invasive set of techniques for treating aneurysms and blood vessel narrowing or stenosis. It is associated with fewer complications than open surgery, and reduces the risk of death significantly. Over the last 10 years, the number of newly developed minimally invasive techniques to treat vascular disease has increased. “They really changed the way that we treat patients with vascular disease, where 15 years ago, 100 percent of what I did was surgery. Now only 50 percent of what I do is with a scalpel. The other 50 percent is done with catheters, balloons or stents,” says Dr. Alik Farber, Clinical Chief of Vascular Surgery and Co-Director of Endovascular Surgery at the Boston Medical Center (BMC).

Many aneurysms, for instance, which used to require big abdominal incisions, are now treated with percutaneous endovascular grafts. “And people who have, let’s say, poor circulation because of blockages in the arteries to the legs – we still do surgery for them – but we also do things like angioplasty, atherectomy, and other minimally-invasive procedures, after which patients can go home the same day instead of staying in the hospital for five days.”

Different from open surgery, endovascular surgery is guided by x-ray imaging. “When I do an open aneurysm, the patient’s abdomen is open, my hands are on the aorta, and I decide what graft to use by sight and feel. In endovascular aneurysm repair, the abdomen is closed, so imaging is critically important,” explains Farber. Computerized tomography (CT) scans and magnetic resonance imaging (MRI), he continues, yield very good pictures to derive accurate measurements of various segments of the artery.

Durability

Endovascular surgery, however, is not a panacea. Farber points out that it may not be as durable as open surgery. “Durability may not be important to somebody who’s 80-years-old, but may be very important to somebody who’s 45. I offer a lot of the aneurysm patients who are in their 70s and 80s endovascular repair as long as their aortic anatomy is appropriate. But just a few weeks ago I saw a policeman who was 45 years old and had an abdominal aortic aneurysm, and I fixed that in the open way because it’s more durable in many ways.”

Everything has to be based on the individual patient, and the specific disease process in that patient, Farber emphasizes. Medicines to treat vascular disease, surgery and endovascular surgery are three synergistic modalities. “You can’t say that all endovascular surgery is good and all open surgery is bad,” says Farber. Patients, however, often seem to think that minimally invasive procedures are the best option. “I don’t blame them,” he concedes, “but sometimes open surgery is better.”

Farber points out that it is important that patients go to a vascular physician who performs both types of surgery. “Part of the issues in our field is that there are three major types of specialties that do these procedures: vascular surgery, cardiology and interventional radiology. The advantage that vascular surgeons have is that they can do both open surgery and endovascular surgery, whereas most radiologists and cardiologists are trained to perfrom only endovascular surgery. To a hammer, everything looks like a nail. Unfortunately, some people only do the procedures they know and apply it to everybody. That’s not the right thing to do,” he admits, “but knowing which modality to apply when is indeed the hard part.”

These issues have put the various specialties at odds with one another in many institutions across the world. “At Boston Medical Center”, Farber continues, “we have formed a collaborative Endovascular Unit where vascular surgeons, cardiologists, and interventional radiologists work side-by side with each other to provide the best possible care to patients with vascular disease, be it medical therapy, endovascular surgery, or open vascular surgery.”

Eliminating diseases

Farber is confident that the techniques for endovascular surgery are going to get better and better. Open surgery, he is sure, is going to become less and less common. He would also like to see advancements in medical treatment of vascular disease. “There’s already evidence that you can reverse atherosclerosis with certain lipid-lowering drugs. I think that eventually medical therapy will play a larger role in treating vascular disease than it does now. But I think there will always be need for vascular surgery.”

Atherosclerosis, Farber says, is a field where he is hoping to see more improvement. Atherosclerosis, which affects arterial blood vessels, causes cardiac disease, coronary artery disease, and a large number of strokes – the number one and number two causes of death in the Western world. Needless to say what good eliminating atherosclerosis could do for people’s health.

“It’s a wish,” Farber admits, adding: “The reality of it is this: our tools aren’t there yet. One of the problems with endovascular therapy, for example, is that neo-intimal hyperplasia, or intravascular scarring, can occurs in the artery after you intervene Scarring inside the artery may cause a blockage, which may lead to failure of an endovascular treatment. So I think that there’ll be ways to prevent that better, for instance, drug-eluting stents that are already playing a large role in cardiac disease and its treatment. Similar advances are going be made in the treatment of peripheral arterial disease – but we are far from eliminating any of these diseases.”

Another challenge for Farber is the fact that vascular disease is still a mystery to many people. Questionnaires assessing knowledge about peripheral vascular disease he handed out randomly to people revealed that most of them didn’t know what vascular surgeons do, nor did they have any idea of what peripheral vascular disease is. “That’s the challenging part; we need to educate people about vascular disease and its treatment,” he adds.

Raising awareness

Farber would like more people to know that vascular disease is common as people age, and that it is caused, among other things, by smoking, high blood pressure and diabetes. “People get more aware as various celebrities get these diseases. For example, when Dick Cheney had a popliteal aneurysm treated, that’s how people found out about it. Raising awareness is very important, because the fact of the matter is, the field of vascular surgery has been growing very quickly and there are a lot of exciting ways now to treat the disease.”

One exciting endovascular option worth mentioning, Farber reckons, is the treatment of carotid artery disease with a stent and an embolic protection device, which is a little filter that is placed above the stent. While the stent is placed, the filter catches the debris that is released during the procedure. “Although carotid stenting is currently controversial and it’s still being tested, nevertheless, it’s very exciting,” exclaims Farber.

It is unclear whether carotid stenting is as good or better than carotid endarterectomy, a tried and true carotid open surgical operation. “But industry has put a lot of money into developing carotid stents, and so they’re very interested in bringing them to market to recoop their investment. Right now, carotid stenting is reimbursed by Medicare for a small percentage of patients,” Farber points out, adding: “But it’s still a very exciting field for me – to be able to offer both to my patients, one day doing a carotid endarectomy and the next day doing a carotid stent. What really drives me is the ability to use medical therapy, surgical therapy and endovascular therapy together as I see fit for the different patient situations.”

Dr. Alik Farber is the Clinical Chief of Vascular Surgery and Co-Director of Endovascular Surgery at the Boston Medical Center (BMC).