Intraluminal Treatment Methods
Endoluminal surgical methods (colloquially known as “ stent” or “ balloon” ) include a wide range of techniques that correct a vessel lesion from its interior (its lumen). They are also called minimally invasive methods because with very small incisions in easily accessible sections of vessels, lesions are corrected even in areas where surgical access to the vessels is laborious. This achieves faster mobilization of the patient and faster discharge from the clinic. Although they are not applicable in all cases, endoluminal methods provide a solution to many vascular diseases.
1. Treatment of Abdominal Aortic Aneurysm
With the advent of Stentgrafts in the treatment of aortic aneurysms about 35 years ago, new horizons were opened in their treatment. Although not all aneurysms can be treated endoluminally, this method has allowed many patients who previously could not undergo the classic surgical method with opening the abdomen (see classic surgical methods) , to find a life-saving solution for this condition.
(Stentgrafts) into the lumen of the aneurysm – under continuous fluoroscopy – through two small surgical incisions in the groin area in order to completely cover the “weak” area of the vessel and to exclude the aneurysm from the rest of the circulation.
In some cases of more complex aneurysms (thoracic/abdominal aorta and iliac arteries) that were previously considered inoperable, we can today provide minimally invasive solutions (custom-made)
2. Management of Peripheral Arterial Occlusive Disease (PAOD)
Since the first application of so-called “balloon angioplasty” nearly 60 years ago in PAOD this condition has remained the principal field of application for endovascular techniques in arterial pathology.
The most commonly used endovascular approach is arterial angioplasty using specialized catheters and balloons, as well as the placement of endovascular prostheses made of wire mesh, either covered or uncovered with a synthetic graft—known as stents or stent grafts . The latter may be drug-eluting, incorporating pharmacological agents that improve long-term stent or stent graft performance.
More recently, newer techniques have been introduced, including removal of atherosclerotic plaque using specialized rotating catheter systems in a “burr-like” configuration (Rotationsathere ctom y) as well as fragmentation and absorption of calcified atherosclerotic plaque using special balloons that emit shockwave pulses (intravascular lithotripsy) .
In cases of embolic disease, aspiration catheters may be used to facilitate thrombus removal without the need for a surgical incision, as well as catheter-directed infusion of thrombolytic agents targeted directly to the site of arterial occlusion.
3. Management of Carotid Artery Disease
Although endovascular treatment is not considered the gold standard for the management of carotid artery disease, it has an established role in selected indications for the treatment of internal carotid artery stenosis, a decision that should be discussed by the patient with the vascular surgeon. In the treatment of carotid artery disease, carotid artery stenting may be performed either via a transfemoral approach through the femoral artery, or via a transcarotid approach through the common carotid artery.
A major contraindication to this method, which is associated with an increased risk of intraoperative stroke, is the presence of an intraluminal thrombus overlying the atherosclerotic plaque.
Overall success rates are comparable to those of the conventional open surgical approach (see conventional surgical techniques ).
4. Management of Varicose Veins
In the treatment of varicose veins, endovascular techniques have largely replaced the traditional surgical approach of saphenectomy. In these cases, a catheter is introduced into the lumen of the vein, and thermal energy — delivered either via a laser catheter or a radiofrequency catheter — induces destruction of the venous endothelium of the saphenous vein, resulting in its therapeutic occlusion. However, even in this setting, endovascular treatment is not always indicated. Contraindications include a markedly tortuous course of the vein, a large venous diameter, as well as a short distance between the vein and the skin. Laser technology is also used in the treatment of telangiectasias, by thermally ablating small superficial veins through transcutaneous application.
5. Management of Deep Vein Thrombosis
Endovascular techniques in the treatment of deep vein thrombosis are applied infrequently and only in selected cases, when the clinical presentation necessitates an interventional approach. Such cases include, for example, chronic occlusions of the iliac veins or May–Thurner syndrome, in which venous stents using a technique similar to that employed in PAD . Through this approach, chronic post-thrombotic syndromes can be treated, particularly in younger patients.
In cases of recent deep vein thrombosis, primarily involving the iliac veins catheter-directed thrombolysis may also be performed, with enhancement of the thrombolytic effect through the use of ultrasound-assisted delivery. Additionally, in selected cases and for protection against pulmonary embolism,
special filters may be placed in the inferior vena cava. These devices expand within the vessel in an “umbrella-like” fashion and prevent the migration of small thrombi to the pulmonary circulation.