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STAT

An MUSC blog
Keyword: endovascular

Endovascular techniques have revolutionized thoracic aortic surgery over the past decade, according to Ravikumar K. Veeraswamy, M.D., chief of MUSC’s Division of Vascular Surgery. MUSC specialists stand at the forefront of this innovation.

“Thoracic aortic surgery is where endovascular techniques have had likely the biggest impact, in terms of reducing morbidity and mortality and improving patient outcomes,” says Dr. Veeraswamy. More specifically, he says a progressive approach to endovascular thoracic surgery for aortic dissections can benefit more patients in the short and long term.

An Endovascular Approach to Aortic Dissections

Many patients with a thoracic aortic dissection, a tear in the inner layer of the aorta, are managed primarily with blood pressure control medications. The goal of this is mainly to control patients’ symptoms such as chest pain and prevent the condition from progressing to an acute state, which requires emergency medical attention and has a high mortality rate.

According to Dr. Veeraswamy, a growing body of evidence shows that placing endovascular stent grafts is a better treatment option for aortic dissections and can offer many patients both immediate and long-term benefits.

“We are very forward thinking about thoracic stent grafts for aortic dissections,” says Dr. Veeraswamy. “A lot of patients with this condition are just managed by controlling the patient's blood pressure and pain and having them follow up as an outpatient. Here, we use a thoracic stent graft to help improve the natural progression of the disease.”

Endovascular stent graft surgery repairs an aortic dissection from the inside of the vessel to improve patients’ symptoms and prevent potential long-term and life-threatening complications such as stroke.

Endovascular Aortic Dissections: Who is a Candidate?

Dr. Veeraswamy’s team has particular expertise in treating acute aortic dissections that require emergency treatment. His success treating more complicated type B dissections with this endovascular approach was recently published in The Annals of Thoracic Surgery.

“Based on my work with acute, complicated, type B dissections, which have a fairly poor prognosis, we were able to reduce the mortality and stroke rate to just under 4 percent,” he explains. “We had successful treatment in approximately 80 percent of patients — sometimes even more than that.”

Dr. Veeraswamy says he’s happy to see any patient who has a thoracic aortic problem. “We have access to new stent grafts and new techniques that may allow us to treat patients who cannot be treated at other facilities,” he explains. “We have lower profile devices, and we have the ability to treat patients who have a difficult anatomy as it pertains to the great vessels of the aortic arch or the abdominal vessels.”

Endovascular Aortic Dissections: Expertise Required

While Dr. Veeraswamy notes the benefits of treating thoracic aortic dissections with this endovascular approach, he admits it’s a technical procedure that involves many moving parts.

“This procedure is fairly complex and requires advanced imaging systems, specialized technology, and a lot of expertise on the part of the surgeons and the rest of the team,” he says.

MUSC’s vascular surgery program brings together a comprehensive team, advanced technology and expertise. Each of those components is crucial to optimize outcomes and minimize complications, says Dr. Veeraswamy. “These procedures really need to be performed at a tertiary care facility, with experienced practitioners, and a whole team of people looking after patients,” he says.

“I personally have a lot of experience treating this disease process,” he adds. “I'm hopeful that we can help the patients in South Carolina — both in the short term and long term — by utilizing the latest available technology to effectively manage aortic dissection and improve patients’ lives.”

For more information, contact Dr. Veeraswamy at veeraswa@musc.edu
 

intracranial stenosisAggressive medical management is the treatment of choice for patients with severe atherosclerotic stenosis (70%-90% ) of the arteries in their brain, according to the results of the 27-site VISSIT trial (NCT00816166) reported by Zaidat et al in the March 24 issue of JAMA. These patients are at extremely high risk of recurrent stroke, and it was hoped that reopening the artery via an endovascular intervention and using a stent to hold it open would reduce that risk. According to MUSC Health stroke neurologist Marc I. Chimowitz, MBChB, who led the earlier 50-site SAMMPRIS trial (NCT00576693) in the same population of patients, “The VISSIT trial confirms the findings from the SAMMPRIS trial that intracranial stenting for symptomatic intracranial arterial stenosis is associated with an unacceptably high risk of stroke and that aggressive medical therapy is the treatment of choice for these patients.” Aggressive medical therapy is defined as dual antiplatelet therapy, intensive risk factor management (systolic blood pressure <140 mm Hg, low-density lipoprotein <70 mg/dL), and a lifestyle modification program. Both SAMMPRIS and VISSIT were stopped early because patients in the endovascular intervention and stenting arm of the trials (who also received aggressive medical management) had a much higher-than-expected rate of both ischemic and hemorrhagic stroke and those in the aggressive medical management arm had a lower-than-expected rate. In an editorial accompanying the JAMA article by the VISSIT investigators, Chimowitz notes that some had questioned the SAMMPRIS results, attributing the increased rate of stroke to the two-pass endovascular intervention it used (on the first pass,  angioplasty was performed to widen the artery and on the second pass the stent was deployed). These critics speculated that a balloon-mounted stent, which could widen the artery and deploy the stent on a single pass, would be less likely to increase the risk of stroke. Balloon-mounted stents were used in the endovascular therapy arm of the VISSIT trial, and even higher rates of stroke were seen than in SAMMPRIS, definitively establishing aggressive medical management as the safest and most effective treatment in these patients and drawing into real question whether stents will have a role in even limited subgroups of these patients in the foreseeable future.

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