France embraces laparoscopic-assisted AAA surgery

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Philippe Piquet explained that the H̫spital Sainte-Marguerite carries out traditional surgery, endovascular surgery and minimally invasive surgery, but that the choice of treatment is highly dependant on the pathology.

For carotid artery disease, carotid endarterectomy remains the first choice, but carotid stenting is used for selected patients. Although this has been carried out extensively in patients considered high risk for surgery, Piquet is reticent when it comes to expanding this to normal risk patients without evidence from a

randomised clinical trial. Therefore, the hospital is involved in the French Endarterectomy versus Angioplasty in patients with Severe Symptomatic Carotid Stenosis (EVA-3S) trial.

For thoracic aortic aneurysms, Piquet and his colleagues have extensive experience in endovascular treatment. In addition, they have carried out endovascular repair of Type B dissections in the descending thoracic aorta and for traumatic rupture of the descending thoracic aorta.

Carotid surgery remains first choice

The EVA-3S trial was affected by problems with one of the protection device used – PercuSurge. However the trial is now back in full swing, having recruited new centres, from both the public and private sectors.

Piquet said, “As I see it for the moment, carotid surgery is evidently the technique of reference and therefore one does not consider carotid stenting as the first choice.

Stenting, he claims, should only be used for patients that are at high risk from surgery, due to either medical risks or difficult anatomical carotid access. “All patients, where the risk from surgery is considered important, are considered and proposed by us for carotid stenting.”Piquet explained that for all other patients surgery is standard, except for those who agree to be included in the EVA-3S protocol.

Piquet goes unprotected

Piquet’s team do not use protection devices in carotid stenting, but rely exclusively on pharmacological protection. Piquet said that this was firstly because the efficacy and safety of mechanical protection had not been demonstrated, secondly because “it is a complication of a procedure that is meant to be simple”and finally because of the cost.

Leading the way

Although Piquet’s centre has an interest in aneurysms of the lesions of the descending thoracic aorta, it abandoned all AAA stent graft implantations, with respect to lesions of the infra-renal abdominal aorta in November 2000 because the late results with this procedure were found to be disappointing.

“In this, Piquet said, “we were a bit ahead of the recommendations of the AFSSAPS [Agence Fran̤aise de Securite Sanitaire des Produits de Sante] and way ahead of the recommendations of the rest of the world.”With the suspension of the endovascular technique, Piquet’s clinic has developed a minimally invasive technique. Aneurysms of the aorta are treated mostly in a conventional surgical way, although assisted by a minimally invasive retroperitoneal video camera.

Piquet said that for him to return to the endovascular procedure would require proof that it worked, without the need for close follow, and the failure of the minimally invasive techniques, which seems unlikely as enormous progress is currently being made in this area.

With the video-assisted minimally invasive technique, the length of time in hospital is as short as with a stent graft and after effects or scars are minimal.

Piquet sees a big future for laparoscopic-assisted surgery, “not complete laparoscopy, but assisted by laparoscopy. He says that at the moment in France many people already do this and little by little, he expects the use of this technique to become more wide spread.

So at the abdominal aorta level, Piquet’s hospital has completely stopped doing endovascular procedures but as he says, “We are very endovascular at the level of the descending aorta, doing around 10 cases of descending thoracic aortic cases endovascularly a year.

Collaborative approach

Although Piquet agrees that there is a kind of competition with interventional cardiologists and radiologists, he says that he works very closely with the radiologist Professor Bartoli.

“In terms of endovascular, thoracic aortic lesions and all that there are always two names for us – always the radiologist and the surgeon – always Piquet-Bartoli or Bartoli-Piquet.

Threat from cardiologists

Interventional cardiologists are another story, however. In France, interventional cardiologists are now saying that they want to deal with superficial femoral arteries, iliac arteries and carotid arteries. Piquet believes that surgeons and interventional radiologists will continue to evolve together, while in parallel the activities of interventional cardiologists will increase, pushed by industry, to include peripheral and carotid lesions, even renal and the digestive system – as Piquet says “the lot.

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