Seung-Woon Rha, MD

Korea University Guro Hospital
Seoul, South Korea
He has stated that he has no financial interests related to this article.
Dr. Rha may be reached at swrha617@yahoo.co.kr.

What is the prevalence of endovascular SFA therapy as compared to surgical?

In Korea, there is a higher prevalence of endovascular therapy than surgery, and the prevalence is stable (neither rising nor falling). In our hospital, there are limited experts in the vascular surgery department, and procedural outcomes in the interventional radiology department are not compatible with the interventional cardiology department. Most endovascular procedures are performed by cardiologists in the department of interventional cardiology.

How would you describe device availability in your country, both in types of devices and different vendors within each class?

A wide variety of wires, including specialty/crossing wires are available from numerous vendors. Many options are available for percutaneous transluminal angioplasty balloons over 0.014-, 0.018-, and 0.035-inch systems, including noncompliant balloons and several DCBs, such as Lutonix (Bard Peripheral Vascular, Inc.), Passeo-18 Lux (Biotronik, Inc.), and In.Pact (Medtronic). Similarly, there are numerous balloon-expandable and self-expanding stents, as well as the Zilver PTX drug-eluting stent (Cook Medical) and stent grafts such as Viabahn (Gore & Associates).

In what ways does reimbursement (both government and private if applicable) affect device use? Which device classes are most affected?

The Korean reimbursement program is mostly government supported. Patients pay around 20% of the total cost of the endovascular procedure. DCBs and stents may get the best benefit from the insurance system.

Are there any historic or cultural forces unique to your country that have affected the penetration of endovascular options?

The only one limitation is conflicts among different specialties, including cardiologists, radiologists, neurosurgeons, and vascular surgeons.

How do most physicians receive training in endovascular therapies in your country?

Most training is done by specialists in major endovascular centers, including my hospital. We maintain a regular, hands-on teaching program weekly and annually. There are many scientific meetings and conferences that cover endovascular therapy in Korea, and those meetings can provide good educational content for young interventionists.

What is your personal strategy or algorithm for treating:

• Short, focal lesions: Atherectomy, POBA, and subsequent DCB.

• Long lesions: Prolonged simple balloon inflation and DCB. Focal provisional stenting in flow-limiting dissection, particularly in SFA disease.

• Calcified lesions: Simple balloon, plaque modification with the SilverHawk or TurboHawk atherectomy device (Medtronic), scoring balloon or cutting balloon angioplasty, and then noncompliant balloon. Provisional stenting in case of flow-limiting dissection.

• CTOs: Intraluminal wiring first and sometimes CTO devices such as TruePath (Boston Scientific Corporation) or Frontrunner (Cordis Corporation) can be used. If unsuccessful, a reentry device (Outback catheter, Cordis Corporation; OffRoad, Boston Scientific Corporation) can be used. Once successful wiring is finished, then POBA and/or DCB and/or provisional stenting.

• In-stent restenosis: Plaque modification by atherectomy, scoring balloon, or cutting balloon, and then high-pressure, noncompliant ballooning. Subsequent DCB use and provisional stenting.

• Claudicants: Mainly medical therapy and rehabilitation program (regular exercise). If the program results are not satisfactory, selective endovascular therapy will be performed.