There are several areas yet to be satisfactorily traversed by endovascular technology and the common femoral artery is one area. While not completely a no stent zone, stents and interventions in the CFA do poorly compared to the open surgical alternative. As vascular surgeons we know that the key to inflow problems is the produnda femoris arteria and she does not tolerate being ignored, stented across, or ballooned too much. I have tabulated some areas that are still in the purview of open surgery in no particular order :
1: systemic infection
2: failure of stent grafts
4: thoracic outlet obstructions
6: SVC syndrome after failure of interventions
8: popliteal entrapment
9: hypothenar hammer syndrome
10: very large thoracoabdominal or juxtarenal aortic aneurysms (until we get FDA approved off the shelf devices)
11: dialysis access
12: extreme limb salvage
13: severe aortic occlusive disease
14: CKD on the cusp of dialysis
15: congenital vascular disease
17: trauma/contaminated fields
18: low risk patients
19: common femoral artery
20: subclavian artery/innominate artery
21: carotid endarterectomy -for now
The list is open ended and you may add in the comments below, but the list in some parts is esoteric. The data is sobering if you read “Predicted shortfall in open aneurysm experience for vascular surgery trainees,” by Dua et al in the 10/2014 JVS. When I trained, I graduated with about 50 open AAA under my belt. Dua et al are predicting 10 per trainee in 2015, and 5 per trainee by 2020.
Percutaneous access for EVAR and TEVAR does several things. First, the procedure becomes shorter by an hour or two, and (don’t discount not having nursing count instruments because the case was percutaneous). Second, the patients experience far less discomfort and it is easier to discharge them the next day when they have a bandaid versus an incision. And this leads to the third thing: not having an incision means it is far less likely that a groin infection will occur, especially in the obese.
There are three things which you must do before undertaking pEVAR. First, you have to become comfortable with using the Perclose S device in 6F-8F access -about 5 to 10 successful closures will do. You should become facile with the deployment of the sutures and closure of the access point. Avoid small arteries or heavily calcified arteries. This leads to the second point -all of your groin access should be ultrasound guided -this has been shown to improve results in pEVAR (Ref 1). I am a firm believer that the source of groin access complications starts with the initial needle stick. The 18g needle is basically a short 11 blade rolled up into a cylinder, and during groin access without ultrasound imaging, one can shear branch arteries, skewer arteries, dissect plaque, and access too proximally or distally, or into the profunda femoris.
The third need is access to 3D reconstruction software and multislice CTA. This gives you powerful ability to predict which patients are more suitable for a percutaneous approach, and which should have a cut down, and with 3D virtual reality reconstructions, you can plan where the incisions will be. In the skinny patient, this is not a pressing issue, but in the merely obese and the frankly obese, and the super obese, choosing to go percutaneous and avoiding a groin complication, which may be the one thing that debilitates the patient far more than a stent graft deployment, becomes an easy decision with experience.
As you build your 6-8F Perclose experience, you may notice that having too tight and subcutaneous tract can result in the suture catching on SQ fat, and not closing, or that bleeding won’t surface properly and create a hematoma under Scarpa’s fascia, often after the patient gets to the recovery room. Expanding on this principle, as you leap to 12F access and preclosure, I recommend you try this -make a 10mm incision, and using a tonsil clamp, pop through Scarpa’s fascia and seat the tips of the clamp under ultrasound on top of the soft part of the CFA that you intend to access. Gently spreading creates the space that you need to deploy the sutures and ensure that any bleeding will exit the skin and not dive under the fascia. It amounts to an ultrasound guided dissection of the common femoral artery. Before you remove the tonsil, you gently maneuver a micropuncture (always) access needle between the tines of the tonsil clamp until it gets to the artery -this keeps the eventual wire going through the tunnel you just made.
12F can usually close with a single Perclose, but start practicing by placing two Perclose sutures in a 10 oclock and 2 oclock orientation. Once the sutures are in, I make sure the two ends of the suture are pulled out and the end loop of the suture is on the artery and I clamp these sutures to the drapes medially and laterally depending on how I deploy the two sutures. This also helps avoid catching the suture and driving it into the aorta.
After performing EVAR or TEVAR, I remove the sheath, leaving a wire -typically the stiff wire originally supporting the sheath and deploy one of the sutures. This first suture should cinch down onto the artery and substantially decrease the bleeding coming from the access site. I then deploy the second suture, and if the bleeding has stopped or is a steady dribble, I remove the wire. If pulsatile bleeding persists, I recinch the sutures using the knot pushers. If this decreases flow, I remove the wire, otherwise, I place a dilator, stop the bleeding and cut down. Cutting down after SQ dissection means merely dividing skin and tissues over the dilator, and the artery is easily visible for suture placement. If I remove the wire and there is still some bleeding, and usually there is, I place Gel-Foam soaked in diluted thrombin into the tract, reverse heparin, and hold pressure for 10-20minutes. It is very rare to have to convert after this is done.
The skin is closed with an absorbable 4-0 monofilament suture, and skin glue. I usually use the micropuncture needle to give an ilioinguinal field block with Marcaine. This gives 24hrs of pain relief.
A note about incisions. Usually, with 3D VR imaging of CTA, the CFA and its quality (size and absence of plaque), and location relative to the inguinal crease can be ascertained. I try to make the access point at the inguinal crease or distally, as this goes under the subpannus of groin fat rather than through it.
I sincerely believe sheath size is not the limiting factor to percutaneous access. Rather, it is the common femoral and iliac artery. Zakko et al at the University of Florida just published their experience on the obese with percutaneous TEVAR (ref 2), and found that while the arteries were deeper, the technical success rate of staying percutaneous (over 90%) was no different between their obese patients non-obese patients. The predictors of failure were poor access artery quality and size. I believe that you can select for patients most likely to succeed and greatly reduce failure. In this population, groin complications are potentially life threatening, and avoiding an open groin exposure is valuable.
Unless you are going out and setting up shop on your own, which is very unlikely, you will be signing a contract. The contract shapes your work life and forms the foundation of your business model. Not understanding this will set you up for headaches. It is worthwhile not only to have a lawyer review it, but also a business savvy physician.
Every medical community has a Jabba the Hut, who is obvious, but there is usually a hidden Sith Lord as well.
People generally will behave in ways that reinforce their worldviews. Add to that the fact that most people stop picking up new ideas or techniques after training, and you have people who practice as much on belief over evidence. This becomes dangerous in hospital privileging committees which are often a tool for killing off young competitors before they pose a threat. The Torquemadas and vascular Taliban are out there, young one, waiting to pounce on your first complication with that new-fangled whatchamacallit.
The easy way to grade the livability and economic level of a town or a burg is looking at what car dealerships are there. Similar metric –is there sushi made by an actual Japanese sushi chef?
Technically, you may press the EMTALA based federal law that you only need to be on call every third day to get paid for any extra days of call.
Veins and dialysis access are far more complex and common than what you may think working for the chairman at Humanity’s Best Hospital. So are limb salvage and wound care.
You are only as good as your team. As nice as you are, patients will hate you if you have an uncaring office staff or hospital rounding crew. As good as you are, your results will be poor without excellent anesthesia, critical care, and floor nursing. Take good care of your partners.
Be careful about high paying jobs in tiny hospitals with no other vascular surgeons. The reasons for this are legion, and frankly, no matter how good you are, you need to be aged like good steak, and that means partners who have been out for a while seasoning you. Also, being solo means it is impossible to find coverage for vacation, unless you put it in your contract that the hospital or employer will pay for locums coverage during your vacation or fly you back first class if you need to come back from vacation and then return you to vacation with offsets for extra days –I have seen all of this and it can happen as long as you negotiate it.
Strive to get better, and that means keeping track of metrics like OR times, contrast volume, fluoroscopy time, blood loss, length of stay, and complications, for standard cases like: Elective Open AAA Repair, EVAR, carotid endarterectomy, infrageniculate bypass with vein. You should get better every year.
Open surgical skills are going to be far more valuable than you think, and it’s not the anastomosis. If all you want to do is the anastomosis and you think you “did the case” if that is all you got to do, you have been fooled by the oldest staff trick in the book. The value is in figuring out first why an operation is chosen, how it is performed, and how it is healed, and having plans B, C, D, and E. Even when an endovascular approach is planned, you have to have in mind the open alternative.
The NYT reports the increasing use of hospital EMRs and registries to help make clinical decisions based on experience not yet published. Of course we must use all the tools available within our databases which is an extension of our knowledge. But I also get the other side of the argument.
The reading of papers can be just that -a passive run through received wisdom, or a critical exercise that can mean life or death when it comes to the medical literature. Dr. Mastracci last year did a wonderful thing by offering a few papers on how to judge the evidence. What the critical reader does is akin to what a pawn broker does when a purchase is considered. There are objective criteria, qualitative criteria, and the gut feeling of value. Do not discount the last, but apply the first because not all that shines is gold.
The graphic is a painting I did several years ago meant to be a market sign for a vascular surgeon in some faraway place. I get no proceeds from their sale, but if I do, they will be turned over to a vascular related charity or foundation.
When conduit is limited, or PTFE or cadaver vein is being considered, in the setting of occluded SFA stents, I have found that it is possible and perhaps preferable to attempt removal of these stents using remote endarterectomy.
The CTA, particularly with 3D reconstruction, is helpful in planning these cases.
The additional material needed is fluoroscopy and endovascular skills. Directing a subintimal Glidewire helps free the stent and aid passage of the Moll ring dissector.
Adding cold saline seems to help shrink the stents. A plaque free distal end point allow the stents to be removed with a gentle tug.
I put these patients on coumadin anticoagulation. Surveillance is needed for recurrent stenoses -typically these occur randomly as focal TASC A stenoses, and likely represent remnant medial tissues that have caused intimal hyperplasia. This may be particularly amenable to treatment with drug eluting balloons. Failure as thrombosis typically is limited to the treated vessel without the embolism seen when PTFE grafts fail. Failure tends to occur in smokers. Inability to pass the dissector is usually seen in patients with heavy calcification -diabetics, renal failure, and I would avoid attempting remote endarterectomy in these patients. When the dissectors fail to pass, cutting down and directly endarterectomizing the vessel and resuming remote endarterectomy is feasible. The common femoral artery is repaired with a patch. I try to avoid having to place a distal stent and when a tapered end point, as in a successful carotid endarterectomy, is achieved, usually unnecessary.
Parts of this was presented at Midwest Vascular in 2008.
Here is a link to the current issue of Cardiac Consult where I have a case report of a difficult EVAR. In it also is a feature on our vice chair, Dr. Timur Sarac, and his bioabsorbable stent, and Dr. Eric Roselli of the Cardiovascular Surgery on stent grafting of ascending thoracic aortic dissections, for which he received special recognition at todays State of the Clinic address by Dr. Cosgrove.