Health x Wellness
Differences between endovascular surgery and open vascular surgery
Endovascular surgery is considered minimally invasive compared to open vascular surgery.
There has been a shift of practice towards endovascular surgery (minimally invasive) as skills and techniques become available, as opposed to open vascular surgery.
Patients benefit from the perspective that there are no big cuts, less morbidity, and less recovery (down) time. There are problems associated with durability, for example, how long the good results lasts, and how many times one will need to re-intervene.
We discuss the trend with Dr John Wang, Consultant General Surgeon, Vascular & Endovascular Surgery, PanAsia Surgery Group and find out more about the conditions and benefits of endovascular surgery.
the Active Age (AA): What’s been your observation regarding the shift towards endovascular surgery in the US compared to Singapore?
Dr. John Wang (JW): Interestingly, the pendulum seems to have swung towards endovascular surgery more than it should. When I moved from the US in 2014, I realised the issue of vascular skill-based imbalance was even more pronounced in Singapore. It is imperative that a vascular surgeon possesses both open surgical and endovascular skills in order to be able to provide the best treatment options for patients.
Having been involved in residency and fellowship training for both general and vascular surgery in the US, and recognising that the typical clinical practice of a contemporary, competent vascular surgeon is approximately 70 percent endovascular and 30 percent open surgery, training of new vascular surgeons can be a challenge due to limited case loads and hence experience especially in open vascular surgery.
These deficiencies are magnified as fewer surgeons retain the skill for open surgery, hence less is imparted to the next generation of vascular surgeons, and the limited population size which dictates the case-load experience.
What ends up happening is only endovascular treatment is offered to patients most of the time.
In a more balanced environment, open and endovascular surgery should be complementary and not mutually exclusive. Failure of one type of therapy can be buffered by the other, or hybrid procedures (open combined with endovascular) can be performed to achieve the best results.
AA: Can you share the key differences and benefits between endovascular surgery and open vascular surgery?
JW: In open surgery, as its name implies, we address the vascular problem from the outside through open incisions. Endovascular literally means inside the vessel, hence in this form of therapy we address the vascular issue from inside the vessel.
A simple analogy is a clogged pipe in your house that leads to your kitchen sink. When you turn the tap on, the water only dribbles and you have a pile of dirty dishes that clearly needs a healthier water supply to clean. When you call the plumber (vascular surgeon), he informs you that there is a segment of pipe in the adjacent wall that is clogged.
He offers you two ways of fixing it. Either replace the blocked pipe with a new segment (bypass) or try and sneak through the blockage through an opening in the pipe (tap end) and clear the blockage (balloon angioplasty) and reinforce the freshly cleared pipe with an internal scaffold (stent) to prevent it from closing off again.
So, in the first option (open surgery) to replace the clogged pipe, your plumber will have to hack the wall to get to the pipe in order to replace the affected segment. This is analogous to the incisions in open surgery to gain access to the vasculature from the outside, although I will emphasise that it is done in a much more sophisticated fashion. After the pipe segment is fixed, the wall will have to be repaired for your kitchen to function normally again.
Similarly, patients who undergo open surgery will have incisions that will take time to recover from the pain, to heal, and to function optimally.
In the second (endovascular) option, it is minimally invasive as we are treating the blockage from an access point into the pipe. In re-establishing flow, all the maneuvers are internal and there are no big incisions to heal from. Hence recovery time is fast and down-time is minimal.
The physiological toll on the body is bigger in open surgery because it involve incisions, more blood loss, and potential peri-operative complications.
Some patients are deemed not fit for open vascular surgery, e.g., patients with severe multiple co-morbidities or the elderly. Some patients are fearful of surgery and will not agree to incisions.
However if able to be performed, open vascular surgery is usually considered the standard of care, with the best durability.
Endovascular surgery can be performed with less morbidity and is effective therapy. However, its long term durability is still measured against the results of open vascular surgery. It is generally recognised that 10 percent to 15 percent of patients may need re-intervention for recurring problems in the future.
However, we can offer endovascular treatment to more patients including those who have complex co-morbidities and older patients, who would otherwise be disqualified for open vascular surgery.
AA: What are examples of conditions that require either type of surgery?
JW: Most treatable vascular conditions have both open and endovascular options, as the latter techniques were developed to achieve similar results to open surgery while taking into account the underlying diseases.
Examples:
- Carotid artery disease that causes strokes (carotid endarterectomy vs. carotid artery stenting)
- Thoracic aortic aneurysms (thoracic aorta aneurysm bypass graft repair vs. thoracic endovascular aneurysm repair/TEVAR)
- Thoracic aortic dissection (thoracic aortic graft replacement vs thoracic aortic stenting)
- Abdominal aortic aneurysm/AAA (open AAA repair with graft vs endovascular aortic aneurysm repair/EVAR)
- Lower extremity peripheral arterial disease/PAD (endarterectomy, or bypass with vein or synthetic graft vs. peripheral artery angioplasty, drug coated balloon/DCB-angioplasty, stenting, or drug eluting stent/DES)
- Chronic venous insufficiency and varicose veins (Saphenous vein high-ligation and stripping + phlebectomy vs. endovascular ablation with laser/radiofrequency/mechanochemical/or adhesive glue)
- Renal artery stenosis that causes refractory high blood pressure (open renal artery endarterectomy or bypass vs. renal artery stenting)
- Arteriovenous malformation/AVM (open excision vs. endovascular embolization)
- Renal dialysis access creation (arteriovenous fistula/AVF or graft/AVG creation vs tunneled catheter placement, and endovascular maintenance of AVF/G with balloon angioplasty or stenting)
AA: Which of these conditions are prevalent in Singapore?
In order of most common to least common:
- Hemodialysis for kidney failure – access issues with AVF/G malfunction requiring maintenance
- PAD with inadequate blood leading to critical limb threatening ischemia (CLTI)
- Leg/foot amputation (high incidence of diabetes in Singapore predisposes this)
- Chronic venous insufficiency
- Varicose veins with leg pain and swelling
- Aortic or arterial aneurysms with risk of rupture, hemorrhage or death
- Thoracic aortic dissections
- Carotid artery disease
AA: When patients are offered endovascular surgery, what are some key questions and considerations they should ask to help with their decision/consideration?
JW: What is the BEST treatment for me taking into consideration my diagnosis, its severity, the prognosis, my age, medical history, and expectations?
What are the benefits and risks of the recommended treatment?
What are my alternatives to the recommended treatment?
Photo by PanAsia Surgery Group and by JAFAR AHMED on Unsplash
