Cath Lab Digest

I am returning now from the Society for Vascular Surgery (SVS) Meeting in Boston. I was honored to be asked to co-moderate one of the post-graduate courses offered by the SVS the day before the meeting. Ten endovascular experts, with a special interest in EVAR, spoke about surveillance, endoleaks and late failure management.

One point is very clear to me: we have made a tremendous amount of progress since Dr. Parodi’s initial EVAR report in 1990, but on the other hand, we still have not even come close to reaching a consensus about EVAR follow-up. CTA? Ultrasound? Pressure sensors? Treat type II leaks? Don’t treat type II leaks? Etc…

It was clear to me that everyone in the audience, by a show of hands, felt that surveillance (lifelong) was necessary. Many people used CTA imaging. Others used ultrasound. Very few people in this group used pressure sensors. Some used a combination of imaging modalities. So…twenty years later, we still are unsure of how to safely follow our patients after EVAR.

The same issue is true for endoleaks. There seemed to be a consensus about treating type II leaks with aneurysm sac expansion. But many people sent these patients to another physician to treat the problem. Most people did not think we needed to treat type II endoleaks with a stable or shrinking aneurysm sac. But there was some discussion about treating type II leaks identified at the time of endograft insertion. There was also a discussion regarding pre-emptive embolization of the inferior mesenteric artery to prevent type II endoleaks. So…twenty years later, we still are unsure of how and when to treat endoleaks.

Late failures are becoming a bigger issue now that FDA-approved devices have been available for over a decade. Migration, fatigue, fractures. These issues are becoming a concern. Endovascular management can be useful, but open options need to be entertained. We are still learning how to deal with these issues.

I was awed by how much we still have to learn. Devices are improving and new trials are coming soon. It is clear to me that we can better define how to perform surveillance, treat endoleaks and manage late endograft failures.

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Ross Milner, MD, FACS is associate professor of surgery at Loyola University Chicago Stritch School of Medicine. He was recruited to Loyola from Emory University School of Medicine in Atlanta, where he was associate professor of surgery.

Dr. Milner graduated Cum Laude from the University of Pennsylvania, where he also completed medical school. He was chief resident in surgery at the Hospital of the University of Pennsylvania. He completed fellowships at the University of Pennsylvania and University Medical Center in Utrecht in the Netherlands. Dr. Milner is currently Chief of the Division of Vascular Surgery and Endovascular Therapy at Loyola University Medical Center, Stritch School of Medicine in Chicago, Illinois.