Back to Vascular Web

 Use of Endovascular Therapy in the Management of Peripheral Vascular Disease

Thomas F. Panetta, M.D., Teruo Matsumoto, M.D., Rodney A. White, M.D.

Includes:

  • Lytic Therapy
  • Balloon Angioplasty
  • Endoluminal Stents
  • Stent Grafts
  • Angioscopy
  • Endoluminal Ultrasound
  • Embolization

I. General

1. To understand the basic principles of emerging technologies in vascular and endovascular surgery.

2. To develop a working knowledge of the equipment, techniques, technical problems, troubleshooting and recovery techniques.

3. To understand the physical properties of devices including but not limited to wires, catheters, balloons, coils, stents , stent -grafts, filters and delivery systems. To understand the physical properties, basic engineering and evolution of devices as they relate to their clinical applications, implantation, biocompatibility, tissue reactions and interactions, graft-metallurgical interactions, wound healing, limitations and overall use in the treatment of vascular disease.

4. To understand the indications, applications, complications, management and results of imaging modalities, basic techniques, newly developed techniques and implantable devices used to treat vascular disease.

II. Imaging Modalities

1. To understand radiation physics, safety, risks, cellular effects, somatic effects, dose responses, monitoring, shielding and variations in x-ray equipment as they relate to both patients and personnel including preventative measures for safety.

2. To understand basic principles and equipment used for fluoroscopy and arteriography . To obtain a working knowledge of contrast media, road-mapping, imaging techniques, measurement techniques, parallax, hand and power injection techniques and film sequencing.

3. To understand the basic principles of intravascular ultrasonography (IVUS). To obtain a working knowledge of B-mode imaging, transducers and catheters.

4. To understand the basic principles of angioscopy . To obtain a working knowledge of endoscopes and fiberoptic technology, imaging and irrigating equipment, and channel instrumentation.

5. To understand the techniques used for preoperative, intraoperative and postoperative imaging, measurements and evaluation of endovascular techniques including ultrasonography , magnetic resonance imaging, computerized axial tomography including helical techniques with 3 dimensional reconstructions and angiography.

6. To understand the accuracy, utility, limitations and clinical importance of each modality.

III. Basic Techniques

1. To obtain a working knowledge of basic endovascular techniques. To understand individual techniques and obtain a knowledge base for standard and emerging technologies.

2. To understand the proper use of needle, catheter, guidewire , dilator and introducer techniques used to gain access to the vascular system and perform vascular interventions.

3. To understand the techniques and mechanisms of angioplasty and atherectomy .

4. To obtain a working knowledge of pharmacological and mechanical methods of thrombolysis .

IV. Emerging Technologies

1. To obtain a working knowledge of self expanding and balloon expandable intravascular stents . To understand delivery techniques, rationale for use and retrieval/recovery techniques.

2. To understand the various types and uses of occlusion techniques including sclerosing agents and occlusion devices. To obtain a working knowledge of coils, temporary and permanent occlusion balloons, and the variety of covered stent occluding devices.

3. To understand and obtain a working knowledge of endovascular grafts, covered stents and stent -grafts for the treatment of vascular disease. This includes the variety of delivery systems, attachment devices, covered stents , and stent -graft combinations and devices. The values and limitations of each of the available and potentially available devices should be understood.

4. To have a working knowledge of adjunctive interventional procedures required as retrieval, recovery or “bail out” procedures in endovascular surgery including endovascular and open techniques.

5. To understand laparoscopic and laparoscopically assisted vascular techniques for both arterial , venous and adjunctive vascular procedures.

6. To understand the role of brachytherapy in preventing intimal hyperplasia, both as an independent modality or in combination with metallic devices.

7. To understand and have a working knowledge of venous filters and venous devices.

V. Clinical Applications

1. To understand and have a working knowledge of endovascular and interventional techniques utilizing percutaneous and surgical access for the diagnosis, management and treatment of traumatic arterial and venous injuries.

2. To understand and have a working knowledge of endovascular and interventional techniques utilizing percutaneous and surgical access for the diagnosis, management and treatment of arterial occlusive disease.

3. To understand and have a working knowledge of endovascular and interventional techniques utilizing percutaneous and surgical access for the diagnosis, management and treatment of aneurysmal disease.

4. To understand and have a working knowledge of endovascular and interventional techniques utilizing percutaneous and surgical access for the diagnosis, management and treatment of cerebrovascular disease.

5. To understand and have a working knowledge of endovascular and interventional techniques utilizing percutaneous and surgical access for the diagnosis, management and treatment of venous disease including arteriovenous malformations.

6. To understand the pathophysiology and management of intimal hyperplasia and recurrent disease after endovascular intervention, endovascular graft placement and insertion of an implantable device.

7. To understand the treatment of acute and chronic complications of endovascular techniques and devices. To understand the pathophysiology and management of arterial injuries, endoleaks , migration, embolization , delivery system failures and attachment device failures.

8. To have a working knowledge of recovery, retrieval and “bail out” procedures for endovascular procedures. This includes both catheter based and surgical procedures.

References

1. White RA, Fogarty TJ, Baker WH et al. Endovascular surgery credentialing and training for vascular surgeons. J Vasc Surg 17: 1095-1102, 1993.

2. Veith FJ. Transluminally placed endovascular stented grafts ( TPEGs ) and their impact on vascular surgery. J Vasc Surg 20: 855-860, 1994.

3. Clagett GP, Silver D, Veith FJ et al. Impact of new technology on vascular surgery training. J Endovasc Surg 2: 133-135, 1995.

4. Clagett GP. Training and credentialing in endovascular surgery for vascular surgeons. In White RA, Fogarty TJ, editors. Peripheral Endovascular Interventions, St. Louis, 1996, Mosby .

5. Yao JST, Pearce WH, editors. Progress in Vascular Surgery, Stamford , 1997, Appleton & Lange.

6. Graduate Medical Education Directory 1993-1994, ed 79, Chicago , 1993, American Medical Association.

Posted June 2010