Selected Podcast

Minimally Invasive Vascular Surgery

Listen as Edward Woo, MD, director of the MedStar Vascular Program, and Misaki Kiguchi, MD, vascular surgeon with MedStar Heart & Vascular Institute, discuss the latest advances in treatments of vascular disease and how minimally invasive technologies can provide better patient outcomes.
Minimally Invasive Vascular Surgery
Featured Speaker:
Edward Woo, MD and Misaki Kiguchi, MD
Edward Woo, MD, is director of the MedStar Regional Vascular Program. In this role, Dr. Woo oversees vascular surgery for MedStar Health. He is also chairman of the Department of Vascular Surgery at the MedStar Washington Hospital Center and a professor of surgery at Georgetown University. Dr. Woo performs all types of vascular surgery and has a keen interest in aortic disease, specifically aortic aneurysms. He has a large practice in peripheral vascular disease and carotid disease as well as all aspects of vascular surgery. Dr. Woo has published more than 100 papers, and he has led numerous clinical trials. He is known and respected throughout the world and is asked to lecture internationally for his expertise in vascular surgery.

Learn more about Edward Woo, MD

Misaki Kiguchi, MD, is a vascular surgeon with the MedStar Heart and Vascular Institute (MHVI) with office hours in Washington, DC and Chevy Chase, MD.

Learn more about Misaki Kiguchi, MD
Transcription:

Melanie Cole (Host):  Technologic advances over the past decade have had a major impact on the treatment of vascular disease and created a new and exciting work environment for vascular surgeons. My guests today are Dr. Edward Woo, he's the Director of the MedStar Vascular program; and Dr. Masaki Kiguchi. She's a vascular surgeon with the MedStar Heart and Vascular Institute. Welcome to the show, doctors. So, Dr. Woo, I'd like to start with you. What types of treatments have traditionally been done for patients with vascular disease?

Dr. Edward Woo (Guest):  Well, thanks for having us, Melanie. Traditionally, with vascular disease, we would perform a lot of open surgical procedures that required larger incisions, would really push the patients back in terms of their ability to recover for longer periods. Now we've come about with multiple new technologies that really create more minimally-invasive techniques that sometimes, they're just a little poke in the skin, and we can have patients back on their feet the same day and back to normal.

Melanie:  Dr. Kiguchi, have open bypasses been associated typically with significant morbidity, mortality, and had an impact on the quality of life for the patient?

Dr. Masaki Kiguchi (Guest):   Melanie, I think it definitely has. The minimally-invasive techniques puts people back on their feet, most of them are actually outpatient procedures, and so the patients can go home that same day, and oftentimes without the use of large incisions. The patients tolerate these procedures much more, and so not only do they stay in the hospital a shorter amount of time, they are able to actually get back to their quality of life much faster.

Melanie: Dr. Woo, have percutaneous interventions such as balloon angioplasty with or without stenting and other revascularization techniques, have they required more re-intervention than open bypass? What have you seen?

Dr. Woo:  I think it kind of depends upon the patient and the disease process. The reality of everybody's different, every pathology's different, and sometimes, when we intervene, whether it be with an open bypass or a percutaneous procedure, it can require re-intervention to keep it going. However, a lot of situations, these patients can have one intervention or one procedure and go on for the rest of their life with success.

Melanie:  Dr. Kiguchi, what are some indications for peripheral vascular angioplasty? What are you using?

Dr. Kiguchi:  Well, I think that we can put these back into two categories: peripheral vascular disease involves either the arteries or the veins. With arteries, the most common is just doing a percutaneous transluminal angioplasty with and without stent. As Dr. Woo had mentioned, it really depends on the patient, the patient's comorbidities, the lesion, and the characteristics of the lesion whether you use the stent or not. That is most common, percutaneous, the angioplasty that we use but there are other methods of treating blockages, especially in the artery that involves stents, atherectomy, and other devices.

Melanie:  Speak about a few of those, if you would, Dr. Kiguchi?

Dr. Kiguchi:  As we just mentioned, the transluminal angioplasty involves a balloon that makes a lumen so that the blood can flow through the blockage. Sometimes, if the blockage is resistant to the ballooning, we place a transluminal stent within that lesion to keep that area open. In addition, we can use atherectomy devices. That is to break up the blockage itself and to create a lumen so that the blood can flow distally. 

Melanie:  Dr. Woo, have you seen a resulting decrease in complication rates that might have helped angioplasty develop into an independent therapeutic procedure with its own indications and contraindications instead of being used as an alternative to surgery?

Dr. Woo:  I think the answer to the question is really kind of both. There definitely is a decrease of complications just because it's a percutaneous procedure. It's more minimally-invasive, and patients get back on their feet quicker, so even if you think about just the long-term complications of being in a hospital for a period of time; people get pneumonias, or urinary tract infections. Things like that are all avoided because the patients are out of the hospital the same day. Those things have led to percutaneous procedures being an alternative to bypass, but because of the results we've seen with these percutaneous procedures and the minimal complications, I think that we've become more willing to treat patients earlier and give them therapeutic options that we otherwise probably would not have subjected them to in order to perform a bypass, just because it was such a bigger procedure. So, I think patients nowadays with more mild to moderate claudications, so pain when they walk, we will treat on an earlier basis with angioplasty just because it's so minimally-invasive and we know the risks are so low.

Melanie:  Dr. Woo, as public enthusiasm continues to increase with regards to minimally-invasive vascular techniques, where do stents fit into this picture? They're hearing about absorbable stents, so speak about that.

Dr. Woo:   So, as you can imagine, the field continues to move with improving and new technology. The field has evolved significantly in the last 20-30 years and one of the new things that everybody's hearing are these bio-resorbable stents and really what this is is basically, when there's a narrowing in the blood vessel, we treat it initially with a balloon angioplasty, which opens up the blood vessel, and then we may or may not place a stent, which is a lattice structure to help prevent recoil of that lesion or that narrowing. Now, the problem with these stents is long-term, it can act as a nidus for what we define as entemohyperplasia. So the body, in a way, is kind of rejecting that stent, and having cellular deposition around that stent that can lead to narrowing in the medium- to long-term. So, the stents work really well in the short term to prevent immediate recoil, but long-term may actually be a problem in terms of forming new stenoses. So, where the bio-resorbable stents come in, they allow for an immediate support or lattice structure to prevent that short-term recoil, and then over time, they dissolve to prevent that more medium- or long-term potential for restenosis.

Melanie:  Dr. Kiguchi, do you feel that advances in technologies such as Dr. Woo's discussing allow surgeons to perform even more anatomically challenging procedures than before? Are you seeing that?

Dr. Kiguchi:  Absolutely. I think we are continuing to challenge ourselves with pushing the percutaneous techniques so that we can treat safely and effectively tougher lesions, not just anatomically, but also in the severity of disease as well.

Melanie: Dr. Woo, in addition to some of these new devices, how have developments in gene therapy and brachy therapy brought several new minimally-invasive options to the treatment of peripheral vascular diseases?

Dr. Woo:  I think we're still really early there. There's a lot of excitement and enthusiasm about gene therapy, but really, we're just not quite there yet. I think, you know, in another 5-10 years, we're going to actually see some real therapeutic options in terms of that field, but right now, it's really just not mature yet.

Melanie:  Dr. Kiguchi, to wrap up your portion, tell the listeners what you would like them to know about minimally-invasive vascular surgeries and where you see it going on the horizon. What's exciting to you?

Dr. Kiguchi:  I think the treatment of peripheral vascular disease today is vastly different from the traditional invasive open treatments that were performed in the past. Breakthroughs that happen every day in minimally-invasive treatment has pushed sort of outpatient procedures to the forefront and so that patient can really get back on their feet as quickly as possible. So, we definitely can continue to sort of push these procedures as long as they are safe and effective for the appropriate patients and so that they can actually get back to their daily life.

Melanie:  And, Dr. Woo, from a patient's perspective, they hear “vascular disease”, right away they go thinking about surgery, and you mentioned claudication, but sometimes, exercise can be a limiting factor if they do suffer from claudication. What do you tell patients and what do you want other doctors to tell patients about living with and managing their peripheral vascular diseases?

Dr. Woo:  I think the most important thing, first and foremost, is to see a vascular specialist to have this discussion. And, really, a lot of treatments need to be tailored and be very patient-specific and patient-oriented. Symptoms in one patient that may require treatment, may not necessitate treatment in another patient. And so, you really have to tailor the treatment options and decisions for every single patient individually. For instance, there may be one patient that is, where their life is significantly inhibited by the fact that they can't walk three or four blocks and want to exercise and be more active and that claudication prevents that and if it's a straightforward intervention that can be done percutaneously, it probably makes sense to do it; whereas, in another patient that is really not very active, doesn't walk that much, never is going to walk three to four blocks, and is not limited to that, I think in those patients, going ahead and trying to treat those lesions may not make as much sense.

Melanie:  Thank you both for being with us today. You're listening to Medical Intel with MedStar Washington Hospital Center and for more information, you can go to www.medstarheartinstitute.org. that's www.medstarheartinstitute.org. This is Melanie Cole. Thanks so much for listening.