How has your background and training in interventional radiology benefited your practice of endovascular aneurysm repair (EVAR)?

Dr. Teigen: My background and training in interventional radiology have provided me with extensive imaging and endovascular catheter skills. These skills are paramount for preoperative evaluation of aneurysm patients, intraoperative problem solving and the placement of grafts, as well as for secondary procedures, such as treating endoleaks.

What made you want to add EVAR to your practice?

Dr. Teigen: EVAR has always been part of my practice. Providing this service allows me to treat all vascular patients, both those with occlusive disease and those with aneurysmal disease. My training and experience lends itself well to treating these patients.

Do you think device enhancements such as lowerprofile delivery systems will help enable more nonsurgeons to perform EVAR?

Dr. Teigen: Obviously, these smaller devices require cutdowns less often, and therefore, allow physicians without cutdown skills to perform the procedure more often. Even with smaller devices, however, we still need better closure devices to more predictably close even these smaller arteriotomies. More importantly, smaller devices will allow us to treat patients with smaller and more tortuous access vessels, especially in women.

In your opinion, what is the ideal setting in which to perform EVAR? Who are the physicians and other personnel in the room, what kind of imaging is used before, during, and after the procedure, and what types of devices are readily available?

Dr. Teigen: Computed tomography (CT) scanning, and occasionally angiography, are necessary for the preoperative evaluation of these patients, which includes the need for possible preoperative branch vessel embolization. The ideal setting in which to perform EVAR is in an endovascular suite with a fixed imaging system. This optimizes the imaging that is necessary for the accurate deployment of the graft. Inventory should be available in all sizes for at least one, if not two or more, of the commercially available endografts. Experienced endovascular and surgical personnel, if cutdown is required, should be in the room. For follow-up, a CT scan should be done at 1 month, 6 months, 1 year, and yearly after that, with angiography and intervention as necessary to treat endoleaks or other complications such as stenoses or occlusions. Until smaller devices are routinely available, it is advantageous to have surgical closure available.

What are some of the clinical trials you are currently participating in?

Dr. Teigen: We have recently completed W. L. Gore & Associates (Flagstaff, AZ) and Cordis Corporation (Bridgewater, NJ) endograft trials and are continuing with a Cook Medical (Bloomington, IN) thoracic endograft trial.

Are there any early lessons you have learned from these studies?

Dr. Teigen: Lower-profile devices will allow the treatment of patients with small access vessels, and larger-diameter main body grafts that are now available can treat larger superior necks. Grafts allowing more accurate placement at the renal vessels, as well as fenestrated grafts to treat very short necks, need to continue to be refined.

In what ways do you think the Internet has influenced patient preference between EVAR and open surgery? Have you experienced this in your practice?

Dr. Teigen: Patients are much better informed and often present with preconceptions of how they want their aneurysm treated based on Internet information. In my practice, patients now usually present wanting only endovascular repair, given its lower morbidity, more rapid recovery time, and perceived lower morality.

What advice would you offer to other interventional radiologists who are interested in performing EVAR?

Dr. Teigen: It is necessary to have an active clinical practice that will allow direct referral of patients to you for endograft repair. Having access to an endovascular suite, as well as cutdown and arteriotomy closure skills, are also helpful.

Corey Teigen, MD, is Managing Physician Partner at the MeritCare Hospital Vascular Center in Fargo, North Dakota. He has disclosed that he is a paid consultant to Cordis Corporation. Dr. Teigen may be reached at (701) 234-6236; corey.teigen@meritcare.com.