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Areas of Expertise
Minimally Invasive & Endovascular Therapies

In the past, most vascular procedures were performed through large incisions that required  hospitalization and a prolonged recuperation time. Over the past decade, many of these procedures have been replaced by endovascular procedures that are performed through a small tube placed in the artery located in the groin area (see image). Endovascular procedures are like operating on the arteries and veins from the inside. Blockages and aneurysms in the arteries or veins can be treated with balloon angioplasty, the use of stents and/or atherectomy (removal of the plaque blocking the vessel). Following an endovascular procedure, patient recovery is quick and the need for hospitalization minimized.

Open Surgery versus Endovascular Repair

With balloon angioplasty, a balloon is delivered to a site of critical arterial blockage via the small tube placed in the artery. The deflated balloon catheter is threaded through the vascular tree, placed across the site of narrowing, and the balloon is inflated. This opens the narrowing which is usually caused by atherosclerotic plaque (hardening of the arteries) or scar tissue. At times, the removal of obstructing plaque by atherectomy can also be used in addition to balloon angioplasty to improve the final procedural result. The best candidates for balloon angioplasty and atherectomy procedures are patients with a relatively short narrowing of the artery or complete short occlusion of the artery, especially the larger arteries in the abdomen. These techniques have been used with greatest success in the iliac arteries and for some blockages in the arteries in the thigh and below the knee. However, they can actually be applied to virtually any artery or vein in the body.

Intraoperative percutaneous iliac angioplasty
Above: Center physicians perforn an endovascular procedure on the iliac artery. Fluoroscopic image of arterial anatomy is displayed on monitors at left. (Inset) Pre-angioplasty aortogram demonstrates eccentric left common iliac artery lesion and tubular external iliac stenosis.

Stents are small metallic devices that are sometimes used in conjunction with balloon angioplasty. The stents are placed inside the artery or vein and act as a scaffold to hold the vessel open. For example, if a balloon can be inflated adequately but, because of elastic recoil, an artery does not remain open, a stent can be placed to serve as scaffolding to hold the artery open. There is evidence that stents will prolong the benefits of balloon angioplasty in certain locations, namely in the iliac, carotid, renal and lower extremity arteries. Stents are placed through the same puncture that is used to perform balloon angioplasty.

Stents
Above: a) Collapsed stent placed through stenosis of artery.
b, c) Balloon dilatation of stenosis with deployment of metallic stent.

Another technique that is used in the treatment of blocked vessels is thrombolysis, which uses clot-dissolving drugs to open the blockage. Thrombolytic therapy has an important, but limited, role in the treatment of long-standing blockages. It provides the best results for patients with relatively recent occlusions of the arteries and veins by clot. Thrombolysis is also performed through a groin puncture, threading a catheter to the site of occlusion and delivering the clot-dissolving drug directly at that site. With this method, the highest concentration of the drug is given directly where it is needed, while minimizing the effects of the drug on other parts of the body. Thrombolysis can also be combined with mechanical devices to expedite the removal of occluding clots.

Endovascular techniques are not only used to treat vessel blockages, but can be used in the management of other conditions such as aneurysms. An aneurysm occurs at a site of a weakened vessel wall, the danger of which is the risk of vessel rupture and bleeding. A stent graft is a tube that can be placed inside of the weakened vessel like a sleeve and act to take the pressure off the weakened area, thereby minimizing  or eliminating the risk of rupture. The most common aneurysms treated with this method occur in the abdomen, but stent grafts are also used to treat aneurysms of the thoracic aorta and vessels such as the renal and popliteal arteries.

Aortic Stent Graft Placement

While endovascular procedures currently are not appropriate for all situations, as technology evolves  these techniques will be applicable to a wider range of patients. A core strength of the Center for Vascular Care is that Center physicians are well trained, experienced, and current with the latest treatments for any vascular problem. Center physicians provide a comprehensive assessment, diagnosis and, depending on the each patient’s unique situation, the most current open or endovascular procedure when required.

 

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University of Southern California Department of Surgery
Keck School of Medicine of USC
1520 San Pablo St., Suite 4300, Los Angeles, CA 90033-5330
Email: vascular@med.usc.edu
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