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Vascular Surgery: The Tufts Medical Center Difference

06/21/2013
In the realm of vascular surgery, a number of capabilities set Tufts Medical Center apart from other institutions in the region, good reasons – among many – to refer patients with vascular issues here. Mark Iafrati, MD, Chief of Vascular Surgery, explains:

Open Repair of Complex Aneurysms

“When vascular surgeons started doing endovascular aortic repair (EVAR) of abdominal aortic aneurysms about ten years ago, roughly 20 percent of patients were deemed appropriate for this approach,” he says. “Now these endograft devices are in their fourth generation and many more patients – nearly 80 percent – are candidates for the less-invasive EVAR approach.

“As a result, the number of open operations for aneurysm repair has diminished so much that many community surgeons don’t feel comfortable doing these more difficult cases, and there’s some fear that low volume could translate into poor results,” Iafrati continues.

“So our referrals lean toward complex patients who need open surgery,” he says, noting that these are commonly those with aneurysms extending beyond the renal or mesenteric arteries. “While most centers see a mix of 80/20 EVAR/open, we’re closer to 60/40. So we remain high-volume, high-skill practitioners in these types of procedures, and our excellent patient outcomes reflect that.”

In addition to an experienced OR staff, post-op care is important, Iafrati notes. “Our volume is high enough that our staff is familiar with all the subtleties of post-op management, and we deliver excellent care with a relatively short length of stay and fewer blood transfusions,” he says.

Repair of Prior Endografts
“Among patients who undergo endovascular aneurysm repair, there’s a fairly common complication called an endoleak,” Iafrati says. Normally, the aortic stent-graft used for EVAR excludes the aneurysm from the circulation by providing a conduit for blood to bypass the sac. But in 20 to 30 percent of EVAR patients, there is persistent blood flow within the aneurysm sac following the procedure. The most common is a type II endoleak, which occurs due to the presence of pre-existing patent branch vessels arising from the aneurysm sac – underscoring the importance of continued post-EVAR surveillance.

“In many cases, the endoleaks resolve on their own,” he continues, “but in maybe five to 10 percent of cases, the aneurysm will expand. In these scenarios, we get a lot of referrals to eliminate the leaks.”

“Sometimes we can get at it by doing in through the artery,” he explains. “Other times, we insert a needle through the back and directly puncture the aneurysm sac. Then we can guide catheters into the sac and its feeding branches and seal them with coils or glue.

“Here at Tufts Medical Center’s CardioVascular Center, interventional radiologists, cardiologists and vascular surgeons collaborate on these percutaneous translumbar puncture cases,” he says. “It’s done under local anesthesia and takes about an hour. While open repairs of endoleaks are an option, the vast majority of patinets are successfully managed with this minimally invasive approach, yielding tremendous benefits for the patient.

“As we see the bar lowered for placement of endografts and patients get further out after treatment, we anticipate that the numbers of these types of cases will increase,” Iafrati notes.

Acute or Chronic DVT and Central Vein Occlusions
“Subcutaneous heparin injection has been a great advance for treating fairly limited blood clots in the calf or lower thigh,” Iafrati says. “If clots are extensive or go to the pelvis, however, and you treat with just blood thinners, resolution can be slow and incomplete. Patients can end up with chronically scarred veins that don’t open, pain, discoloration and even ulcerations – post-phlebitic syndrome.”

“We’re pretty aggressive about helping folks at different stages of this disease process,” he continues. “If someone presents within two to six weeks after onset of an extensive clot in the leg, various catheters can be placed into the vein to immediately remove the clot using a clot retrieval device, or we can directly administer the thrombolytic drug tPA to dissolve it. This quick removal dramatically improves the long-term prospects for a healthy limb.”

“If people come in outside that six-week window, however, they’re likely to have sequelae of obstruction including swelling,” Dr. Iafrati says, “and the clot is too organized to dissolve with medication or mechanical retrieval. We’re left with trying to create new channels for the blood to return to the heart, and this is one of our niches.”

“Using a minimally invasive approach from a groin puncture, we can wind our way through or around blocked veins,” he explains. “We have a series of instruments including a radiofrequency-tipped wire we use to open up these occluded veins.”

“I believe we were the first in New England to use this approach about  three years ago, and published our initial experience in the Journal of Vascular Surgery,” he continues. “You need a clear sense of exactly where you’re supposed to go when you’re burning through something occluded, and we take full advantage of outstanding imaging capabilities in our procedure rooms.” These include a three angiography suites and a new hybrid OR with 3D spin imaging capabilities. “We can see the catheter moving through a virtual image of the vessel in real time, and it makes it very safe and effective for getting through blockages,” he adds.

“We also have experience going around blockages using accessory veins typically not addressed by interventionalists or surgeons,” Iafrati notes. “Plus, if there are extensive blockages or scar tissue in the groin, these are most ideally treated with an open operation to place a patch and remove the blockage. 

“Here at the Vascular Center, all these specialists work together” he adds, “so if a patient needs open surgery in addition to minimally invasive interventions, we can get it done.”

Critical Limb Ischemic Interventions
In the last decade, the endovascular approach to treating limb ischemia via stent placement or atherectomy has supplanted femoral distal artery bypass, similar to the increase in EVAR versus open aneurysm repair.

“But data from a large trial comparing surgical bypass to the catheter-based approach as a first line of treatment for limb ischemia followed patients for eight years,” Iafrati says. “And it showed that if a patient is likely to live two-plus years after surgery, he’s better served by more durable bypass operations.”

“At our Center, we have all the tools in our toolbox and can tailor treatment to each patient,” he continues. “We provide all the endovascular approaches when appropriate, but we maintain our expertise in doing bypasses, too; it’s a skill we keep fresh.”

When patients with critical limb ischemia are not suitable for either the open or endovascular approach due to inadequate targets for revascularization, research suggests that up to half will end up with an amputation or death within a year, Iafrati notes.

“We’re looking for a biologic solution to prevent this and are involved in a clinical trial using bone marrow stem cells to help create collateral vessels around blockages,” he explains. In a seven-center, 48-patient pilot study, for which Iafrati served as principal investigator, results were encouraging.

“This pilot study was not designed to achieve statistical significance, but patients randomized to the bone marrow-cell treatment had about a 50 percent reduction in amputation risk, less pain, improved quality of life, and all objective measures of blood flow to the leg increased,” he says. “Based on that encouraging data, we’ve launched a larger trial with 210 patients at 35 centers nationwide.” Iafrati is the lead investigator, and Tufts Medical Center is the lead site.

“It’s pretty cool, and definitely cutting edge,” he says. “And it could prevent amputations in patients who’ve been told nothing can be done.”

“This as well as catheter-based treatments of central venous occlusions really distinguish us,” Iafrati adds. “Nobody else in town is doing what we can do in these areas.”

To refer a patient to Dr. Iafrati and the Vascular Center, call 617-636-5019.