endovascular surgery cp- dr sahal fatah

8/10/2019 Endovascular Surgery Cp- Dr Sahal Fatah

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ENDOVASCULAR SURGERY IN INDONESIA

Sahal FatahDiponegoro UniversityKARIADI HOSPITAL


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20141929 1960

Era of diagnostics

Cardiac and vascular diagnosticprocedures were rapidly developed

(Table 1.1)

Era of therapeutics

Development of interventionalmodalities such as embolectomy,

angioplasty, and atherectomy(Table 1.2)

Evolution of Endovascular Therapy: Diagnostics and

Therapeutics Thomas J. Fogarty and Amitava Biswas

Endovascular therapy is the manipulation ofpathology by an intraluminal approachHistory of endovascular therapy can be dividedinto two 30-year periods.


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Evolution of EndovascularDiagnostics and Therapeutics

Evolution of Endovascular Therapy:Diagnostics and Therapeutics

Thomas J. Fogarty and Amitava Biswas


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Era of Diagnostics(1929 1959)

The surgeon Renaldo Dos Santos ,breakthrough applied to the extremities and todevelop arteriography and aortographyForssmann should be possible to insert acatheter into the right side of the heart through avenous channel and thereby:

monitor cardiac pressuresobtain blood for analysis, andadminister therapeutic agents


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Renaldo Dos Santos, MD,Pioneer surgeon and original

developer of diagnostic arterialvisualization techniques and

technologies

Werner Forssmann, MD,Physician credited with developing

endovascular diagnostics bydemonstrating cardiac assessment

using catheter


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Werner Forssmann inserting acatheter into his antecubital vein

1956 Nobel Prize in Medicine
http://en.wikipedia.org/wiki/Nobel_Prize_in_Medicinehttp://en.wikipedia.org/wiki/Nobel_Prize_in_Medicine


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Sven Ivar SeldingerA radiologist from Sweden. He

introduced technique to obtain safeaccess to blood vessels and other

hollow organs

Andr Frdric Cournand A Surgeons who is known for cardio

catheterizationNobel Prize in Physiology or Medicine

the Anders Retzius Silver Medal of theSwedish Society for Internal Medicine
http://en.wikipedia.org/wiki/Nobel_Prize_in_Physiology_or_Medicinehttp://en.wikipedia.org/wiki/Nobel_Prize_in_Physiology_or_Medicine


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Era of Therapeutics(1960 1990)

Embolec tomy Fogarty The earliest diseaseentity to be approached intraluminally wasembolic occlusion.Balloon An giop las ty Dotter/Grntzig useda balloon catheter made by Fogarty toexpansion of the balloon caused an increase

in the lumen diameter (iliac stenosis). Atherec tomy Simpson developed the ideaof mechanically removing atheroma fromvessels lumen ( atherectomy) .


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Charles Theodore DotterRadiologist The Father of

Intervention . Described angioplasty

in 1964

Dr. Thomas J. Fogarty An American CardioVascular surgeon

inventor of the embolectomy catheter

for removing an embolus, or blood clot


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Andreas Roland Grntzig A German Cardiologist who first

developed successful balloonangioplasty for expanding lumens of

narrowed arteries

Julio PalmazDoctor of vascular radiology . He

got the idea for his stent afterlistening to a lecture by Gruentzigat a conference in New Orleans in

1978.


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Juan C. Parodi, MD,Vascular surgeon and designer

who advanced the clinicaltechniques and applications for thetransluminally placed endovascular

endograft

John B. Simpson, MD,Cardiologist and innovator

of catheter-mediated techniques fortreating coronary artery

atherosclerosis


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Whose responsibility is

Endovascular?

?

?

? ?


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Future Developments

The users of the new technology are oftenshared by multiple specialties. In theendovascular field we have :

CardiologistsCardiothoracic and Vascular SurgeonsVascular surgeonsInterventional radiologists

All threating the same diseases and pathology withthe same or different techniques and instruments.


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Endovascular Practice in Asia-Pacific

Consists of countries with wide diversities in:PopulationEthnicityLanguageClinical practice

The incidence and detection rates of occlusive andaneurysmal diseases are on the rise.The growth of endovascular surgery, depend on:

Device availability

RegulationsSkills

Stephen W.K. ChengProfessor, Department of Surgery, Chief, Division of Vascular Surgery, Queen Mary Hospital, The University of Hong Kong,

Hong Kong, China


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Asia

With modernization and changing dietary habits,we are witnessing an increase in the incidenceof arterial pathologiesThe development of endovascular surgery in

Asia is slow, and most countries have only asmall group of dedicated vascular surgeons.Peripheral vascular surgery is often practiced

within the domain of general or cardiac surgery.


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China

1.3 BillionPopulation

Increasing trend ofspecialization in

vascular surgery

General Surgeons

Vascular SurgeonsChinese

Vascular Society

Vascular surgery is not a popular specialty, but there arelarge individual hospitals and units in major citiesdedicated to cardiovascular and peripheral vascular work.


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> 2,000 casesare performed annually 200 regionalcentersin

EVAR TEVAR is largely carried out by surgeons inoperating theatres.Local training institutions and facilities are very limitedMany vascular surgeons have additional experience inoverseas centers: United States, Australia, or Europefellowships or short-term course


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Japan

80 medicaleducation centers

4 vascularsurgery professors

2,000 membersof Vascular Surgeons 10,000 AAA repairswere done annually

Aneurysm repair (EVAR-TEVAR) and lower limb

procedure majority are performed by cardiothoracicsurgeons (over 80%)Open surgery is largely done by cardiac surgeons, whilecarotid disease is managed by neurosurgeons


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KoreaSimilar to Japan, there are no large numbersof vascular surgeonsInterventional radiologists have traditionallydominated peripheral endovascular work.300 EVARs and 100 TEVARs have beenperformed annually


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Vascular surgery practiceis mainly confined totwo university hospitals

and the rest are performedby general surgeons .

Affordable health carefor all citizens are provided

but expensive deviceswere not included;i.e. endografts and stents.

In general, peripheral endovascular surgery is still notpopular due to reluctance of the patients to undergo

intervention and to pay for expensive devices.Endovascular stent graft remained at this time largelyin the hands of surgeons, working in operating roomsetting either individually or in cooperation withradiologists.

Hong Kong


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Taiwan Vascular surgery only gained recognition as a specialty inthe mid-2000s, when the Taiwan Society for VascularSurgery was established.Prior to this endovascular work was largely in the hands ofcardiologists.There has been a significant volume of carotid andvertebral angioplasty and stenting done by the Division ofCardiology at the National University of Taiwan Hospital.EVAR development was late in Taiwan due to governmentregulations mandating a FDA-type trial before any devicescan be registered for use.


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Thailand

Endovascular surgery has also proliferatedsignificantly in Thailand in the last few years.Initially supported and reimbursed by thegovernment, covering 80% of device costs, there has

been a rapid growth of endovascular stent grafts, butat significant expenses to the government

Malaysia EVAR and other endovascular surgery is limited to avery few private vascular surgeons who have thefacilities and the patients to afford the devices.Currently this remains a very small market.


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India

1.1 Billionof population

70 vascular surgeonsin 2008

10 out of 24

medical schoolshave vascular surgery unit

7 centers

have training program for12 vascular trainees annually

Vascular surgery is still in its developing phase

There are about 5,000 arterial reconstructions peryear, and most of the work is done by cardiac andgeneral surgeons.


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Indonesia

Indonesia has only one vascular surgery

program in Jakarta.

and had two cardiovascular thoracic surgeryprogram in Jakarta and Surabaya.

240 Millionof population

I d i


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Indonesia Hospitals TEVAR and EVAR*

Peripheralendovascular

diagnostic and

treatment **RSPJN Harapan Kita Jakarta Cardiologist

Thoracic Cardio-Vascular

RSUPN CiptoMangunkusumo Jakarta

Vascular SurgeryCardiovascular Consultan

RSUP dr Kariadi Semarang Thoracic Cardio-VascularSurgery

Intervention RadiologyRSUD dr Soetomo Surabaya Cardiologist

Intervention Radiology

RSUD Sanglah Denpasar Thoracic Cardio-VascularSurgery

RSUD Dr. Moewardi Solo Thoracic Cardio-VascularSurgery

RSUD Dr. Zainal Abidin Aceh

Thoracic Cardio-VascularSurgery

* Thoracic-Abdominal Aneurism and Dissecting** Arteriography, PTA, Stenting


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Advantages and DisadvantagesEndovascular

AdvantagesLess invasive

Less hospital length of stayLess morbidity and mortality

DisadvantagesMore expensive


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Indication of Endovascular

CHRONIC LIMB ISCHEMIA : Arteriografi, PTA Stent graft ACUTE LOWER LIMB ISCHEMIA : Thrombolysis , ThromboembolectomyCAROTID AND VERTEBRAL DISEASE : Angioplasty and stentingVISCERAL ARTERY OCCLUSIVE DISEASE : Angioplasty and StentingTHORACIC and ABDOMINAL AORTA : ANEURYSMS AND DISSECTIONSVISCERAL AND PERIPHERAL ANEURYSMS : Endovascular graftingVASCULAR MALFORMATIONS : Embolization, coilingVASCULAR TRAUMA : Arteriografi, EmbolizationVENOUS DISEASE : IVC filter, Venoplasty, stenting

ARTERIOVENOUS ACCESS


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Complication Access Site Complications

Hematoma and False Aneurysms 2-6% Arteriovenous Fistula 0,1-0,2% Access Vessel Thrombosis

Target Site Complications Acute Closure 1-7%Rupture 0,6-1,2%Stent Infection

Distal ComplicationsEmbolizationCholesterol Embolization


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Endovascular therapy is a multidisciplinaryfieldinvolving contributions from surgeons,cardiologists

radiologists, physicists, and engineers.


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Endovascular is theresponsibility of the

Cardiothoracic and Vascular SurgeonVascular SurgeonCardiologistRadiologist

DO NOT BLAME EACH OTHERS


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endovascular surgery cp- dr sahal fatah

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