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Dr. Eric Verhoeven Discusses Endovascular Treatment of Popliteal Aneurysm
At the 2012 VEITHsymposium, Vascular Disease Management spoke with Eric Verhoeven, MD, PhD, from the Department of Vascular and Endovascular Surgery at Klinikum Nürnberg in Nuremburg, Germany, about the use of the Viabahn endograft (Gore) for treatment of popliteal aneurysm. Dr. Verhoeven says this endograft can help a certain subset of patients. Read the interview below to learn more about the Viabahn endograft.
Q: Can you provide a synopsis of your work with the Viabahn endograft?
A: We have used the Viabahn endograft for the exclusion of popliteal aneurysms for more than 10 years. The Viabahn has evolved; in Europe it was called the Hemobahn that opened from hub to tip, then it became the Viabahn that opened from tip to hub.
Now we have new longer lengths, and most importantly a new PROPATEN bioactive surface Viabahn endograft. We use these tubular and very flexible devices to exclude aneurysms and especially popliteal aneurysms. They come in very handy because we are obviously crossing the knee joint and we need a very flexible device to do the job.
Q: Do you feel that endovascular therapy has replaced open therapy for patients with popliteal artery aneurysm?
A: I am trying to avoid the fight between “endovascular” and “open.” I think we have passed that stage where we wanted to prove that one technique is better than the other. There are obviously advantages and disadvantages for every technique, and endovascular is less invasive, easier and more tolerable for the patient, but has got its disadvantages. And I’m not even speaking of the anatomical features of the aneurysm, and patients with totally different levels of activity.
We have old patients, we have young patients, we have active patients, we have inactive patients, we have patients who cannot comply with the anticoagulation therapy that we need after the procedure. We have patients that do not want to give up, for example, gardening on their knees, which is obviously not a good thing when you have a stent graft in your artery.
So, we have to find the right solution for the right patient. I’m trying to move away from which technique is best and move toward which technique is best for this patient and this particular aneurysm, which is what I’m going to present here.
Q: Is there enough information to make an informed decision on which is best?
A: I think with regard to long-term results in suitable patients yes, we’ve applied the technique for more than 10 years. The results are comparable to those of open surgery.
If you look at the literature you will see that the results are roughly in the 80% patency range both for open repair and for endovascular repair, so what we need to do is cherry pick the best technique for each individual patient.
Q: What are the current limitations of endovascular treatment?
A: The graft is still a tubular graft. In some cases I would love to have a tapered graft because sometimes the anatomy is such that a patient has a large diameter artery above the knee and a smaller diameter artery below the knee.
The other anatomical features that come into play are really a good inflow and a good outflow. But that also goes for open surgery. We all know that for open surgery you like to do short bypasses, meaning distal origin bypasses. This is exactly the technique we do with endovascular repair.
But in cases where the patient does not have a good inflow, I would say that endovascular repair is probably less suitable because we would then by open means do a longer bypass starting from the groin to also bypass the diseased superficial femoral artery.
Q: Will those limitations be overcome in the foreseeable future?
A: Some of the limitations will be overcome. There is no doubt that we already have a better graft. The grafts have changed in structure and surface so that they are now less prone to early thrombosis, so this is all very good. We are moving forward, but obviously we will never overcome all of the anatomical limitations. That’s why I’m saying we need to find the right technique for each patient. We will never use one technique exclusively.
Q: Are there any other points you’d like to share on this topic?
A: Quite honestly, I am surprised that the vascular community with all its endovascular enthusiasts still hasn’t embraced the technique for the suitable patients. Many people still think inside the box and say this is not a good technique, which is completely not true. If you apply it in the right anatomy and you deal with the right patients, you are doing well for your patients. In my opinion, about 50% to 70% of patients would benefit more from an endovascular approach than from an open approach.
Dr. Eric Verhoeven is a vascular surgeon who is the medical director of the Department of Vascular and Endovascular Surgery at Klinikum Nürnberg in Nuremberg, Germany. Dr. Verhoeven discloses that he is a consultant to W.L. Gore and a member of their speakers bureau. In addition, he has received grants, honoraria, and travel reimbursement from Gore.
