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ENDOVASCULAR SURGERY IN INDONESIA
Sahal FatahDiponegoro UniversityKARIADI HOSPITAL
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20141929 1960
Era of diagnostics
Cardiac and vascular diagnosticprocedures were rapidly developed
(Table 1.1)
Era of therapeutics
Development of interventionalmodalities such as embolectomy,
angioplasty, and atherectomy(Table 1.2)
Evolution of Endovascular Therapy: Diagnostics and
Therapeutics Thomas J. Fogarty and Amitava Biswas
Endovascular therapy is the manipulation ofpathology by an intraluminal approachHistory of endovascular therapy can be dividedinto two 30-year periods.
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Evolution of EndovascularDiagnostics and Therapeutics
Evolution of Endovascular Therapy:Diagnostics and Therapeutics
Thomas J. Fogarty and Amitava Biswas
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Era of Diagnostics(1929 1959)
The surgeon Renaldo Dos Santos ,breakthrough applied to the extremities and todevelop arteriography and aortographyForssmann should be possible to insert acatheter into the right side of the heart through avenous channel and thereby:
monitor cardiac pressuresobtain blood for analysis, andadminister therapeutic agents
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Renaldo Dos Santos, MD,Pioneer surgeon and original
developer of diagnostic arterialvisualization techniques and
technologies
Werner Forssmann, MD,Physician credited with developing
endovascular diagnostics bydemonstrating cardiac assessment
using catheter
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Werner Forssmann inserting acatheter into his antecubital vein
1956 Nobel Prize in Medicine
http://en.wikipedia.org/wiki/Nobel_Prize_in_Medicinehttp://en.wikipedia.org/wiki/Nobel_Prize_in_Medicine8/10/2019 Endovascular Surgery Cp- Dr Sahal Fatah
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Sven Ivar SeldingerA radiologist from Sweden. He
introduced technique to obtain safeaccess to blood vessels and other
hollow organs
Andr Frdric Cournand A Surgeons who is known for cardio
catheterizationNobel Prize in Physiology or Medicine
the Anders Retzius Silver Medal of theSwedish Society for Internal Medicine
http://en.wikipedia.org/wiki/Nobel_Prize_in_Physiology_or_Medicinehttp://en.wikipedia.org/wiki/Nobel_Prize_in_Physiology_or_Medicine8/10/2019 Endovascular Surgery Cp- Dr Sahal Fatah
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Era of Therapeutics(1960 1990)
Embolec tomy Fogarty The earliest diseaseentity to be approached intraluminally wasembolic occlusion.Balloon An giop las ty Dotter/Grntzig useda balloon catheter made by Fogarty toexpansion of the balloon caused an increase
in the lumen diameter (iliac stenosis). Atherec tomy Simpson developed the ideaof mechanically removing atheroma fromvessels lumen ( atherectomy) .
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Charles Theodore DotterRadiologist The Father of
Intervention . Described angioplasty
in 1964
Dr. Thomas J. Fogarty An American CardioVascular surgeon
inventor of the embolectomy catheter
for removing an embolus, or blood clot
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Andreas Roland Grntzig A German Cardiologist who first
developed successful balloonangioplasty for expanding lumens of
narrowed arteries
Julio PalmazDoctor of vascular radiology . He
got the idea for his stent afterlistening to a lecture by Gruentzigat a conference in New Orleans in
1978.
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Juan C. Parodi, MD,Vascular surgeon and designer
who advanced the clinicaltechniques and applications for thetransluminally placed endovascular
endograft
John B. Simpson, MD,Cardiologist and innovator
of catheter-mediated techniques fortreating coronary artery
atherosclerosis
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Whose responsibility is
Endovascular?
?
?
? ?
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Future Developments
The users of the new technology are oftenshared by multiple specialties. In theendovascular field we have :
CardiologistsCardiothoracic and Vascular SurgeonsVascular surgeonsInterventional radiologists
All threating the same diseases and pathology withthe same or different techniques and instruments.
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Endovascular Practice in Asia-Pacific
Consists of countries with wide diversities in:PopulationEthnicityLanguageClinical practice
The incidence and detection rates of occlusive andaneurysmal diseases are on the rise.The growth of endovascular surgery, depend on:
Device availability
RegulationsSkills
Stephen W.K. ChengProfessor, Department of Surgery, Chief, Division of Vascular Surgery, Queen Mary Hospital, The University of Hong Kong,
Hong Kong, China
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Asia
With modernization and changing dietary habits,we are witnessing an increase in the incidenceof arterial pathologiesThe development of endovascular surgery in
Asia is slow, and most countries have only asmall group of dedicated vascular surgeons.Peripheral vascular surgery is often practiced
within the domain of general or cardiac surgery.
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China
1.3 BillionPopulation
Increasing trend ofspecialization in
vascular surgery
General Surgeons
Vascular SurgeonsChinese
Vascular Society
Vascular surgery is not a popular specialty, but there arelarge individual hospitals and units in major citiesdedicated to cardiovascular and peripheral vascular work.
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> 2,000 casesare performed annually 200 regionalcentersin
EVAR TEVAR is largely carried out by surgeons inoperating theatres.Local training institutions and facilities are very limitedMany vascular surgeons have additional experience inoverseas centers: United States, Australia, or Europefellowships or short-term course
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Japan
80 medicaleducation centers
4 vascularsurgery professors
2,000 membersof Vascular Surgeons 10,000 AAA repairswere done annually
Aneurysm repair (EVAR-TEVAR) and lower limb
procedure majority are performed by cardiothoracicsurgeons (over 80%)Open surgery is largely done by cardiac surgeons, whilecarotid disease is managed by neurosurgeons
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KoreaSimilar to Japan, there are no large numbersof vascular surgeonsInterventional radiologists have traditionallydominated peripheral endovascular work.300 EVARs and 100 TEVARs have beenperformed annually
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Vascular surgery practiceis mainly confined totwo university hospitals
and the rest are performedby general surgeons .
Affordable health carefor all citizens are provided
but expensive deviceswere not included;i.e. endografts and stents.
In general, peripheral endovascular surgery is still notpopular due to reluctance of the patients to undergo
intervention and to pay for expensive devices.Endovascular stent graft remained at this time largelyin the hands of surgeons, working in operating roomsetting either individually or in cooperation withradiologists.
Hong Kong
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Taiwan Vascular surgery only gained recognition as a specialty inthe mid-2000s, when the Taiwan Society for VascularSurgery was established.Prior to this endovascular work was largely in the hands ofcardiologists.There has been a significant volume of carotid andvertebral angioplasty and stenting done by the Division ofCardiology at the National University of Taiwan Hospital.EVAR development was late in Taiwan due to governmentregulations mandating a FDA-type trial before any devicescan be registered for use.
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Thailand
Endovascular surgery has also proliferatedsignificantly in Thailand in the last few years.Initially supported and reimbursed by thegovernment, covering 80% of device costs, there has
been a rapid growth of endovascular stent grafts, butat significant expenses to the government
Malaysia EVAR and other endovascular surgery is limited to avery few private vascular surgeons who have thefacilities and the patients to afford the devices.Currently this remains a very small market.
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India
1.1 Billionof population
70 vascular surgeonsin 2008
10 out of 24
medical schoolshave vascular surgery unit
7 centers
have training program for12 vascular trainees annually
Vascular surgery is still in its developing phase
There are about 5,000 arterial reconstructions peryear, and most of the work is done by cardiac andgeneral surgeons.
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Indonesia
Indonesia has only one vascular surgery
program in Jakarta.
and had two cardiovascular thoracic surgeryprogram in Jakarta and Surabaya.
240 Millionof population
I d i
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Indonesia Hospitals TEVAR and EVAR*
Peripheralendovascular
diagnostic and
treatment **RSPJN Harapan Kita Jakarta Cardiologist
Thoracic Cardio-Vascular
RSUPN CiptoMangunkusumo Jakarta
Vascular SurgeryCardiovascular Consultan
RSUP dr Kariadi Semarang Thoracic Cardio-VascularSurgery
Intervention RadiologyRSUD dr Soetomo Surabaya Cardiologist
Intervention Radiology
RSUD Sanglah Denpasar Thoracic Cardio-VascularSurgery
RSUD Dr. Moewardi Solo Thoracic Cardio-VascularSurgery
RSUD Dr. Zainal Abidin Aceh
Thoracic Cardio-VascularSurgery
* Thoracic-Abdominal Aneurism and Dissecting** Arteriography, PTA, Stenting
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Advantages and DisadvantagesEndovascular
AdvantagesLess invasive
Less hospital length of stayLess morbidity and mortality
DisadvantagesMore expensive
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Indication of Endovascular
CHRONIC LIMB ISCHEMIA : Arteriografi, PTA Stent graft ACUTE LOWER LIMB ISCHEMIA : Thrombolysis , ThromboembolectomyCAROTID AND VERTEBRAL DISEASE : Angioplasty and stentingVISCERAL ARTERY OCCLUSIVE DISEASE : Angioplasty and StentingTHORACIC and ABDOMINAL AORTA : ANEURYSMS AND DISSECTIONSVISCERAL AND PERIPHERAL ANEURYSMS : Endovascular graftingVASCULAR MALFORMATIONS : Embolization, coilingVASCULAR TRAUMA : Arteriografi, EmbolizationVENOUS DISEASE : IVC filter, Venoplasty, stenting
ARTERIOVENOUS ACCESS
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Complication Access Site Complications
Hematoma and False Aneurysms 2-6% Arteriovenous Fistula 0,1-0,2% Access Vessel Thrombosis
Target Site Complications Acute Closure 1-7%Rupture 0,6-1,2%Stent Infection
Distal ComplicationsEmbolizationCholesterol Embolization
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Endovascular therapy is a multidisciplinaryfieldinvolving contributions from surgeons,cardiologists
radiologists, physicists, and engineers.
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Endovascular is theresponsibility of the
Cardiothoracic and Vascular SurgeonVascular SurgeonCardiologistRadiologist
DO NOT BLAME EACH OTHERS
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