What is Endovascular Surgery?
Traditional open vascular surgery involves making a large incision on the area of defect to access the blood vessel to treat various cardiovascular conditions. The term endovascular refers to “inside a blood vessel.” Endovascular surgery is a minimally invasive surgical technique performed under local anaesthesia and involves making a small incision instead of a large incision required for open surgery and passing devices through the blood vessel to repair, unblock, or reroute the blood vessels, often under image guidance.
Indications for Endovascular Surgery
Endovascular surgery is usually recommended when non-surgical treatments such as medications have failed to treat cardiovascular conditions. It is often performed to improve blood circulation to an area of the body where the blood vessels have been damaged or the blood flow has been obstructed, following injury, disease, or other conditions. Some of the common vascular conditions that may warrant endovascular surgery include:
- Peripheral vascular disease: Peripheral vascular disease (PVD), also referred to as peripheral artery disease (PAD), is a common disease that occurs when the blood vessels that supply blood to the limbs and other organs of our body are partially or completely blocked due to plaque build-up, a condition called atherosclerosis.
- Deep vein thrombosis: The condition in which a blood clot forms in the deep veins of the body is referred to as Deep Vein Thrombosis (DVT). Clots form when blood thickens and clumps together. A DVT occurs most often in the deep veins of the leg and thighs.
- Abdominal aortic aneurysm: Aortic aneurysm is a condition characterised by an abnormal bulging of a section of the large blood vessel called the aorta. The aorta is the major blood vessel that carries oxygenated blood from the heart to the different parts of the body. In an abdominal aortic aneurysm, the aneurysm occurs in the section of the aorta that passes through the abdomen.
- Carotid artery disease: Carotid artery disease occurs due to the deposition of plaque (fatty substances) inside the walls of your carotid (neck) arteries. These arteries supply oxygen-rich blood from the heart to your brain. Due to plaque accumulation, the arteries become narrow or even completely blocked. This reduces blood flow to your brain and creates oxygen deficiency, increasing your risk of having a stroke.
- Varicose veins: Varicose veins are enlarged veins caused due to weak or damaged valves in the veins. They appear twisted, bulged, and blue, red, or flesh-coloured. They are swollen and raised above the surface of the skin and are mostly found on the thighs, back of the calves, and inside of the leg.
- Pulmonary embolism: Pulmonary embolism is a sudden blockage of an artery in the lung. The blockage is due to a blood clot in the pulmonary artery that carries blood from the heart to the lungs. Blood clots usually develop in the arteries of the leg or arm and travel to the arteries of the lung.
- Coronary Artery Disease (CAD): CAD is the most common of all heart diseases, and a leading cause of death. CAD occurs due to atherosclerosis, a condition where cholesterol and a waxy substance called plaque accumulate in the coronary arteries (blood vessels supplying oxygen-rich blood to heart muscles) over time, thereby narrowing the artery and reducing the flow of oxygen-rich blood to the heart muscles.
Preparation for Endovascular Surgery
Preoperative preparation for endovascular surgery may involve the following steps:
- A thorough examination is performed by your doctor to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as bloodwork and imaging to screen for any abnormalities that could compromise the safety of the procedure.
- You will be asked if you have allergies to medications, anaesthesia, or latex.
- You should inform your doctor of any medications, vitamins, or supplements that you are taking.
- You may need to refrain from supplements or medications such as blood thinners or anti-inflammatories for a week or two prior to surgery.
- You should refrain from alcohol or tobacco at least a few days prior to surgery and several weeks after surgery.
- You should not consume solids or liquids at least 8 hours prior to surgery.
- A written consent will be obtained from you after the surgical procedure has been explained in detail.
Common Endovascular Surgery Procedures
Some of the common endovascular surgery procedures include:
- Balloon angioplasty and stenting: Angioplasty and stenting is a procedure performed to open narrowed or blocked blood vessels as a result of accumulation of a fatty substance called plaque. During the procedure, a balloon catheter (thin tube) is inserted into the vessel and inflated at the site of the blockage to compress the plaque against the wall of the artery. Your surgeon may also insert a wire mesh tube called a stent along with the balloon catheter to help keep the artery open and prevent it from narrowing again.
- Endovascular aneurysm repair: During an endovascular aneurysm repair, a small incision is made in the leg near the groin. A catheter is inserted into an artery and advanced imaging technique is used to monitor delivery of the catheter carrying the stent-graft to the area of the abdominal or thoracic aortic aneurysm. The surgeon fastens the stent-graft in correct position and removes the delivery catheter. The stent-graft placed inside the aorta prevents the aneurysm from bursting, allowing blood to flow freely without pushing on the weakened area of the artery.
- Carotid endarterectomy: Carotid endarterectomy is a surgical procedure performed to treat carotid artery disease and involves removal of plaque from the carotid arteries of the neck. During the surgery, a small incision is made over the neck to expose the narrowed carotid artery. A plastic tube is placed into the blood vessel, above and below the narrowing or blockage, to re-route the blood flow around the narrowed or blocked area. The artery is then opened, and the plaque is removed. The plastic tube is then removed as normal blood flow has been restored and the artery and skin incisions are closed. The procedure reduces your risk of developing transient ischemic attacks (TIA) or stroke.
- Coronary Artery Bypass Grafting (CABG): CABG is a surgical procedure to bypass a blocked artery of the heart. It involves incising a small part of a blood vessel (most commonly a vein from the leg) and using it as a graft (a piece of living tissue that is transplanted surgically). The procedure is indicated for the treatment of narrowing and blockages in the coronary arteries, which can lead to serious complications if left untreated.
- Thrombolytics therapy: Thrombolytics is the use of “clot-busting” drugs to dissolve or break down blood clots formed in blood vessels to prevent damage and death of tissues. It is often used as an emergency treatment for heart attack, pulmonary embolism, and stroke, when clots block blood vessels supplying the corresponding vital organs of the body - the heart, lungs, and brain. The procedure is also indicated to treat blood clots formed in bypass grafts (blood vessel implanted to bypass a blocked artery) and dialysis catheters (catheters implanted for kidney dialysis use). During the process of thrombolysis, clot-busting drugs are administered intravenously (IV) or with the help of catheters (flexible tubes) directly at the site of blockage. To do this, an incision is made at the groin, wrist, or elbow to access the underlying artery. The catheter is inserted through this incision and threaded to the region of the clot under the guidance of live X-ray imaging (fluoroscopy). Once the catheter reaches the clot, your doctor injects medication to dissolve it.
- Endovenous Laser Ablation: Endovenous laser ablation is a procedure that utilises heat produced from the laser to reduce varicose veins. During this procedure, a small cut is made on the leg and a catheter with a laser fibre is guided into the vein till it reaches the site of abnormality. On reaching the site of treatment, the fibre is made to emit laser energy which produces heat near the blood vessel which causes blood to clot in the vessel and thus destroys the blood vessel. The damaged blood vessel will collapse, shrink, and finally disappear.
Following the surgical procedure, you may experience pain or discomfort for which your surgeon will prescribe medications. You may be allowed to go home in a day or two after surgery. You can usually resume normal activities and return to work within 2 to 4 weeks post surgery. Refrain from strenuous activities and lifting heavy weights for a defined period. Keep your surgical site clean and dry. Instructions on surgical site care and bathing will be provided. You will be advised to take your prescribed medications and make a few lifestyle changes such as quitting smoking, exercising regularly, maintaining a healthy weight, and eating a healthy diet. A periodic follow-up appointment will be scheduled to monitor your progress.
Benefits of Endovascular Surgery
Endovascular surgery is a minimally invasive procedure and provides various benefits including:
- Smaller scars
- Decreased risk of infection
- Less bleeding
- Reduced requirement of transfusion
- Less post-operative pain
- Fast recovery
- Shorter hospital stay
- Quicker return to daily normal activities
Risks and Complications
Endovascular surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:
- Blood clots
- Allergic/anaesthetic reactions
- Damage to adjacent tissues or organs
- Heart attack