Health Care - Cutting-edge vascular treatment offers less-invasive

Union Memorial Hospital's Center for Vascular Intervention is carrying out innovative technologies that emphasize replacing conventional vascular surgery with less-invasive procedures.

Dr. Frank Criado, the director of the department and chief of vascular surgery, noted that as early as 15 years ago technological refinements in equipment and development of new, sophisticated miniature devices were appearing in an ever-quickening pace. While conventional surgery definitely still ranks high, Criado sees the trend toward less-invasive methods as unstoppable and irreversible, since patients prefer minimally invasive procedures over open surgery when given the choice.

Perhaps even more importantly, referring physicians feel the same way. Criado's exciting alternative to open surgery involves the use of stent graft procedures performed under regional or local anesthesia, resulting in shorter hospital stays.

Three of the most common vascular procedures treated at the vascular center by Criado and his team are nonsurgical intervention for severe stenosis (i.e., narrowing) of the internal carotid artery and repair of thoracic (chest cavity) and abdominal aneurysms.

Criado points out that stroke is among the three most catastrophic health problems today. Cervical carotid artery disease is frequently the cause of stroke. However, through early diagnosis and treatment, a large number of these strokes can be prevented.

Endarterectomy (surgery) is still the standard of care, but many patients are high-risk candidates for surgery. That is helping to make percutaneous (i.e., through the unbroken skin) treatment with stenting is an exciting new development.

This approach, called endovascular treatment with balloon angioplasty and stent placement, begins with a puncture in the groin area under simple local anesthesia. Through this puncture, wires and catheters are worked up from the groin to the aortic arch and finally into the carotid arteries, all under x-ray fluoroscopic and angiographic techniques.

The artery is opened with the balloon, and the stent is then placed to keep it open. Patients are hospitalized for one night, with discharge to home the next morning. Access to advanced technologies and extensive experience with hundreds of carotid stent procedures, as done by Dr. Criado and his team, allow Union Memorial to approach even the most difficult situations, often considered inoperable by most surgeons. Some patients are referred by their physicians; others find the center by searching on the Internet

When wires and catheters are placed into any vessel, especially a carotid lined with atherosclerotic plaque, there is a danger of these plaques becoming unstable, then degenerating and rupturing into the blood stream. This situation can cause distal embolization to the brain and the retina of the eye, causing mini strokes or even severe ones.

To protect against such an event, an inverted bell-shaped filter, similar to a miniature umbrella turned inside out, called an AngioGuard, is placed to prevent such embolization. Through this mechanism of protection the risk of procedure-related stroke has been reduced to nearly zero in the last hundred consecutive cases at Union Memorial. As a result, the FDA and the IRB (Institutional Review Board) have given their approval for Criado and his team to carry out the procedure under Investigative Device Exemption protocols.

Thoracic aortic and abdominal aortic aneurysms can also now be treated with similar techniques. Though not common, these aneurysms are especially dangerous, with eventual rupture of the aneurysm and consequent death being the usual result if they are untreated.

Unfortunately, many of these patients also have other significant medical problems which make them poor candidates for conventional surgery. As in the procedure outlined above, a small incision is made in the groin through which a stent is passed. The tubular device is then placed at the site of the aneurysm, relieving the pressure.

In this case also, Criado and his team have been granted an Investigational Device Exemption and Institutional Review Board approval due to their remarkable success with this innovative technique.

Robert S. Coplan, M.D., M.P.H., has spent a half century studying, practicing and writing about medicine and issues facing the health care and biotechnology industries.

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