Date of Web Publication 8-Mar-2019
Bedi VS. Ringside view of evolution of endovascular therapy in the management of aortic aneurysms. Indian J Vasc Endovasc Surg 2019;6:3-4
Bedi VS. Ringside view of evolution of endovascular therapy in the management of aortic aneurysms. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Jul 16];6:3-4. Available from: http://www.indjvascsurg.org/text.asp?2019/6/1/3/253731
In the autumn of 1990, Juan Parodi received a phone call from the President of Argentina: "My secret service has told me that you are doing something new for aneurysms. My cousin has an aneurysm, back pain and severe chronic obstructive pulmonary disease, so please treat with the new intervention." On September 7 in the same year, the president's cousin, a 70-year-old male with a 6-cm abdominal aortic aneurysm, underwent the first successful endovascular aneurysm repair (EVAR) in the Western world, which became widely known to all and was reported in the following year in the Annals of Vascular Surgery.
Initially, the first generation of EVAR devices was bulky and had to be deployed via a 26/28F sheath with access from femoral to brachial artery, and the devices had to be chilled and lubricated with jelly to enable them for deployment. The first EVAR done by our team in India at Army Hospital (R&R), Delhi Cantt, was almost 8 years after the first reported case in 1999, in a 70-year-old male patient of coronary artery disease (post-coronary artery bypass graft [CABG]), who had a large aortic aneurysm with CABG with all grafts blocked. Because he was a poor risk patient for open surgery, EVAR was done using the Boston Vanguard device which was successfully implanted. The patient survived the procedure and lived for almost 13 years after the same. The initial deployments were turbulent due to high profile of devices and difficult deployment strategies, and therefore, we were skeptical whether EVAR would last beyond a few years. We were proved wrong in our own thinking as the next generation of devices such as Excluder, Talent, and Cook devices were introduced into the market and life became somewhat easy thereafter. However, the challenge was to find a patient with a minimum neck length of 15–20 mm and adequate femoral vessel size for deployment of the devices.
All stents mentioned above were deployed by the trigger/pullback mechanism. The only balloon-expandable stent (Lifepath) was introduced in the new millennium, but sank without a trace within 3–4 years of its launch. The second- and third-generation devices were on a lower profile and more user-friendly, and therefore, the instructions for use for these were changed over the years to accommodate a neck length of 10–15 mm and sheath size of <7 mm.
The next issue was to treat patients with leaking aortic aneurysms, which was subsequently attempted successfully in many cases. The only remaining challenge was to place the inventory at short notice for such cases. Once the endovascular therapy for infrarenal aortic aneurysms as well as distal thoracic aneurysm work was streamlined, we were faced with the question: Why can't we offer similar treatment for patients with complex aortic aneurysms?
In 2006, the first visceral debranching was performed by our team at Army Hospital (R&R) in a 33-year-old patient with multiple comorbidities such as coronary artery disease (operated) and renal artery stenosis (poststenting) and a large thoracoabdominal aneurysms which was treated by a single-stage debranching of the renal arteries, superior mesenteric artery, and common hepatic artery followed by EVAR which was successfully performed.
Subsequently, the same strategy was adopted for arch aneurysms, where a combination of aorto-bicarotid, carotid-carotid, carotid-subclavian bypasses were performed along with TEVAR. The predicament in doing visceral hybrid debranching procedures was the higher mortality and morbidity as compared to standard EVAR, and therefore, the role of chimney grafts came in for high-risk patients which was successfully executed by many of our colleagues and our own team on a regular basis.
The evolution of tailor-made fenestrated devices brought about a sea change in the management of complex aortic aneurysm, but the costs were prohibitive and the patient had to wait for 10–12 weeks to get the device. Therefore, this treatment did not become very popular in India, but necessity, being the mother of innovation, led us to making our own fenestrations on the operating backtable before the procedure which gave similar results and has become the standard of care in certain institutions such as Christian Medical College, Vellore, and Sir Ganga Ram Hospital. Today, in many of the patients, a complete percutaneous deployment of devices is being done (percutaneous EVAR) using preclose technology with a couple of ProGlide devices and giving the patient the benefit of a truly stitchless procedure.
During this period, various new promising devices such as multiflow modulator and endovascular aneurysm sealing system (Nellix) were introduced for aortic aneurysms, but long-term results of these are still under controversies.
In conclusion, one can say that looking at the evolution of endovascular technology in the last two decades, and the keen interest shown by innovators and interventionalists alike, it has become clear that the best is yet to come. The EVAR is likely to become the standard of care in the near future, but one has to accept that open surgery will still be the gold standard for some time.