Optimizing Access and Closure
This issue of Endovascular Today deals with an aspect that all endovascular procedures (coronary, EVAR, TEVAR, and peripheral) have in common: the necessity to achieve access to the vascular system. Preferred approaches differ significantly between the various specialties, and there is no consensus on which technique is best. The coexistence of these different ideas among specialties should not be considered negatively, as this diversity has led to a form of cross-pollination that has proven to be very beneficial.
For example, the use of distal pedal access in peripheral vascular interventions is a variant to the radial approach that has already been in use for more than a decade in percutaneous coronary interventions. Nowadays, we can achieve much more with an endovascular approach, without increasing the risk of complications.
It needs to be kept in mind that all these different access techniques require specific operator skills. In addition to this, devices depend more and more on the access route chosen. To perform pedal access procedures safely, smaller introducer sizes were needed (< 4 F), which, in turn, led to the development of angioplasty balloons and stents with crossing profiles that are compatible with these small sheaths. On the other hand, in order to perform peripheral interventions from a radial approach, the French size of the devices is less of an issue; however, with a transradial approach, longer equipment (guidewires, sheaths, and long-shaft balloon catheters and stent delivery systems) is needed. The objective of the articles in this issue is to provide practical tips and tricks, and I compliment all of the authors on achieving this goal.
Herein, transradial and transbrachial catheterization, as well as lower limb distal access for peripheral interventions are addressed, as these approaches are rapidly being implemented around the globe. For the same reason, the classic common femoral artery access route will be discussed in relation to large-bore delivery systems, as required for EVAR, TEVAR, and transcatheter aortic valve replacement.
This edition includes a variety of subjects ranging from venous disease (including an overview of new endovenous therapies and vein center accreditation) to thoracic aortic dissection. The latter article discusses failure modes, complications, and limitations of endovascular treatment and will help in understanding, predicting, and managing both procedure-related and device-related issues.
We also focus on issues particular to the concerns that many physicians face in the workplace today. A preview of the ICD-10 coding system is presented, as well as an article that helps to get your inventions from simply an idea to the marketplace while protecting your intellectual property. The role of physician advocacy in national health care decision making is also discussed.
To conclude this issue, we share a discussion with Yale’s new Chief of Vascular Surgery about his experience in the endovascular field, the US Army, and device development.
I hope you will enjoy this edition of Endovascular Today.
Jos C. van den Berg, MD, PhD
Guest Chief Medical Editor