Interventional radiologists and vascular surgeons are teaming up to treat abdominal aortic aneurysms, thanks to a new endovascular graft that requires the hands-on expertise of both specialties for proper placement.
The collaboration is an inch of détente in the otherwise fierce turf battle over minimally invasive image-guided vascular techniques. In recent years, as the success and utilization rates of various grafting procedures have flourished, cardiologists, neurologists, vascular surgeons, and radiologists have all staked claims to these innovative and lucrative treatments.
But based on the premise that two minds are better than one, the land grab has given way to joint ownership at Somerset Medical Center in Somerville, NJ.
"It's best to have both skill sets in the room," said Dr. Grant Jay Price, chairman of radiology at Somerset Medical Center. "It's a cooperative venture with surgeons. Things can go wrong that only radiologists can help out with, and it’s good to have the surgeon on hand for any complications."
The cross-specialty partnership was formed after Price became interested in adding a new, especially tricky abdominal aortic aneurysm (AAA) grafting procedure to the hospital’s interventional repertoire.
The Ancure stent graft, manufactured by Guidant of Indianapolis and approved by the Food and Drug Administration last year, is inserted into an incision in the groin and, using x-ray guidance, threaded through the femoral artery into the aorta. Once in place, the team expands the graft with a balloon and secures it in place with tiny hooks. Finally, the balloon is deflated and removed.
To learn how to conduct the procedure, Price attended a two-day U.S. federal credentialing program administered by Guidant. But he didn’t go alone. Dr. Edward Buch, Somerset Medical Center’s chief of surgery, also attended.
"The surgeon who accompanied me decided long ago that he wanted to do something on a collaborative basis," Price said. "Now, we go to the operating room with a radiologist and surgeons from two different groups. There is a lot of talent in the room."
Which is good, because threading the catheter is very tricky even in routine cases, Price said. Ultimately the radiologist, not the surgeon, might be the only person who knows the catheter’s precise location, he said.
"Everybody brings something to the pot," Buch added. "Each group must be allowed to do what they're good at to make this work. Surgeons don't know everything about the imaging tricks and wires that the radiologists do, and radiologists don't know everything about blood vessels. We all come together to help the patient."
According to Buch, interspecialty alliances, not financial turf battles, will ensure how complex and innovative procedures like the Ancure stent graft are best administered, and the patient best served. And Price added that turf hasn’t become an issue because surgeons and radiologists decided early on that the Ancure system is a team effort. In addition, the two specialties are able to divide the CPT code for the procedure and therefore share the reimbursement fees, he said.
Although the Somerset team has administered the graft for only about six months, odds are the novel approach will be put to the test in the coming years. The utilization of endovascular interventional procedures is on the rise, thanks in large part to rising demand for the shorter hospital stays stemming from minimally invasive techniques. The Ancure system seems tailor-made for this niche; Buch said it requires a hospital stay of no more than a day or two, while surgery imposes 5-10 days of convalescence.
But the system has drawbacks. The price, ranging from $6,000 to $9,000 for the procedure, makes it costlier than surgery. And there are complications, including the potential for embolization, graft leakage, blood vessel injury -- and a recurrence rate of between 15% and 20%, Buch said.
In FDA clinical trials that involved 538 patients, there was a 90% success rate in phase II testing and a 96% success rate in phase III testing. This was tempered by a 29% rate of leaks, a number of which required additional interventional procedures, according to the Medical University of South Carolina's division of vascular and interventional radiology, which administers a Web site that tracks the clinical trials of aortic stent grafts.
Buch said patients must be carefully selected. Because surgically treated aneurysms have a low recurrence rate, young patients in their 50s might be better suited for surgery, but an older patient who can't withstand the rigors of surgery might be better served with an alternate, minimally invasive procedure, he said.
And at one hospital at least, it appears that such procedures are also prompting specialists to rethink the importance of guarding turf.
"At our institution, the chief of radiology, the chief of surgery, and the chief of cardiology have all come together to work on this," Buch said.
By Dan KrotzAuntMinnie.com contributing writer
February 27, 2001
Related Reading
New Jersey team successfully treats aneurysms with Ancure System, February 7, 2001
SCVIR papers focus on outcomes of AAA repair, March 31, 2000
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