Latest / UF Health MedEd Cast / Open vs Endovascular Aortic Repair: Choosing the Best Option

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Open vs Endovascular Aortic Repair: Choosing the Best Option · UF Health MedEd Cast

• 0:03
  Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with
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  UF Health Shands Hospital.
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  I'm Melanie Cole.
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  And today, we have a panel exploring open and endovascular options for
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  aortic surgery and how surgeons approach treatment when standard endovascular
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  access or repair is not possible.
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  Our discussion highlights how careful understanding of anatomy, surgical
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  planning, and long-term follow-up can help guide treatment decisions for
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  patients with complex aortic disease.
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  Joining me in this panel is Dr.
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  Martin Back.
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  He's a Professor of Surgery and Chief of the Division of Vascular Surgery and
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  Endovascular Therapy at the University of Florida College of Medicine.
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  And Dr.
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  Eric Jeng, he's the Director of the UF Health Aortic Disease Center and an
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  Associate Professor in the Division of Cardiovascular Surgery at the University
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  of Florida College of Medicine.
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  Doctors, thank you so much for joining us today.
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  And Dr.
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  Back, I'd like to start with you.
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  Can you describe a little bit about the current state of aortic surgery?
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  Help us to understand the historical context and current
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  trends in open surgical repair versus endovascular approaches for
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  the treatment of aortic disease.
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  Dr. Martin R. Back:
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  Thanks, Melanie.
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  It's come a long way.
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  You know, currently, endovascular approaches to a lot of aortic
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  pathologies really dominate the field and what's practiced across the
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  country and even around the world.
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  It was 1999 the FDA approval of the first devices for treating infrarenal
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  aortic aneurysms in this country that it kind of opened the door to the
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  endovascular revolution as it was.
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  The complexity of endovascular treatments to now treat kind of branch segments of
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  the aorta, such as across the visceral aorta and across the aortic arch have
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  continued to evolve with the technology.
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  And I think that the endovascular approaches have replaced some of the
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  aortic open operations in many cases, but certainly don't completely replace it.
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  There are needs for open operations that are still performed at all levels
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  of the aorta, and Eric can talk more to some of the thoracic aorta and ascending
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  and arch areas below the diaphragm.
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  There are still open operations that are required for complex anatomies that can't
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  be handled with endovascular therapy.
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  So, open and endovascular approaches I would consider complementary
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  in treating various pathologies.
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  And sometimes in patients, the complexities require hybrid
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  approaches or some combination of endovascular and open approaches.
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  Melanie Cole, MS: Well then, Dr.
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  Jeng, please speak about some of the indications.
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  Let's start with the advantages and limitations of open surgical repair,
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  and then we're going to move on to the endovascular approaches, and
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  we'll compare and contrast those.
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  Dr. Eric Jeng:
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  Thank you, Melanie.
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  I think the open approaches obviously give you a one-stop shop to that pathology,
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  wherever that pathology may be in the ascending aorta, the ascending arch, or
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  even the proximal descending aorta or even the complete thoracoabdominal aorta.
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  That being said, the open approaches frequently have an increased morbidity
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  and at least short-term mortality.
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  The benefit becomes in the short term for the endovascular procedures.
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  But long term, I think you have to have more surveillance in
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  the endovascular procedures as opposed to the open procedures.
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  Dr. Martin R. Back:
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  I'd like to add, we know with treating thoracoabdominal aneurysms and aneurysms
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  and other pathologies below the diaphragm as well, secondary interventions
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  after initial endovascular repairs probably, you know, are required in at
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  least one in five or 20% of patients.
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  And so, surveillance for the patient's remaining lifetime is needed with repeated
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  CT scans in general for that surveillance.
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  The equivalent outcomes have been achieved in the abdominal aorta, for
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  example, between endovascular and open.
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  If the mission of the operation or the procedure is to keep the patient from
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  dying from their aneurysm treatment or keep the aneurysm from rupturing,
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  both of these approaches have been able to accomplish the same mission
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  equally, but with their pros and cons of less morbidity up front with an
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  endovascular approach, a little more morbidity with the open approaches and
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  the need for secondary interventions later with the endovascular thing.
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  So, again, you know, complementary approaches that can be tailored to
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  patients' anatomies both achieving same kind of outcomes which is keeping
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  aneurysms from rupturing, for example.
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  Dr. Eric Jeng:
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  To add to that, Melanie, I think there are parallels even in the
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  cardiovascular surgery or in cardiovascular medicine world.
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  Frequently, patients get stents because they don't want open heart surgery as
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  opposed to coronary bypass operations.
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  And we know long-term in specific disease pathologies, yeah, stents may
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  work in the short term, but at the end of the day, you get more interventions,
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  repeated interventions, when compared to open coronary bypass operations.
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  You'll see that there are certain subsets where the gold standard is open surgery,
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  but depending on what the patients prefer and what their disease pathology
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  and what they look like at that moment in time clinically, that may favor
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  one type of operation over another.
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  Meaning if they're more healthy, maybe they could withstand an open surgery;
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  versus less healthy, an endovascular approach may be the better of the options.
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  Dr. Martin R. Back:
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  And finally, Melanie, you did ask me about, you know,
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  the historical perspectives.
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  I gave you a little bit of kind of the original dates of some of
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  the endovascular interventions.
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  In a thoracic aorta, first FDA-approved devices were in 2007.
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  That being said, endovascular approaches were initially proposed to be able to
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  handle the higher medical risk patient.
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  And so, you were going to be doing endovascular things in sicker people
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  that had higher risks of complications and death from an open operation.
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  Well, that's come and now spread into kind of all risk categories.
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  You know, you give patients a choice, and they want something that's less
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  morbid upfront and a quicker recovery, and something done through smaller
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  incisions and transfemoral approaches to get an endovascular approach
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  compared to a big open operation, longer hospitalization, bigger recovery, and
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  return to functionality for the patients.
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  Dr. Eric Jeng:
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  But this is exactly why an aortic center or multidisciplinary approach
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  is the key concept here, because you get thought leaders in every category.
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  And like we've talked about before, you get less siloing of information.
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  And for the patients themselves, they get a comprehensive approach and a
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  multidisciplinary approach to get the best solution and a customized solution
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  for their customized state of being.
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  Dr. Martin R. Back:
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  And, you know, we meet regularly.
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  The other thing is what Eric and his colleagues do and I and my colleagues
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  do, we overlap quite a bit in the patients that we take care of.
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  And so, it's good to get a consensus from our group.
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  We meet at least twice a month, review many cases with complex aortic anatomies,
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  aneurysms, dissections and the like and, as a group, decide what are the best
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  approaches for some of these patients and recommend that and then perform them.
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  We do a lot of combined procedures together.
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  So in this type of a center of excellence, you're getting the best
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  of his talents and my talents, you know, in treating a given patient.
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  I mean, that gives the patient the best chance of getting through and
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  getting their pathology treated safely.
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  Melanie Cole, MS: Well, that's certainly a comprehensive approach with the importance
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  of that multidisciplinary aspect.
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  So, Dr.
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  Jeng, when we think of the key anatomic and clinical factors, and
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  you mentioned shared decision-making and what the patient really wants.
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  And I'm sure that that is a little bit challenging for patients to think of
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  that open repair and open heart surgery.
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  Tell us a little bit about your management strategies for aortic
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  anatomy when maybe that presents the challenge to your standard endovascular
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  access or repair techniques, whatever their clinical factors might be.
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  How are you working with them, and then how do you help them to make those
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  decisions based on your expertise?
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  Dr. Eric Jeng:
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  Because we work so closely with, I mean, even the interventional cardiologists,
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  the radiologists, the vascular surgeons, we come up with what we think is
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  the best and the simplest approach, and sometimes that's open surgery.
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  We offer the patients all of these decision-making pathways, and they
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  end up having the free will to decide which direction they want to go.
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  That's where the informed consent comes into play, where we explain all the
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  risks, all the benefits, the short-term morbidity, the short-term mortality, the
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  long-term benefits, and that's how we end up deciding one thing or another.
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  We're not peg-holed into deciding either open surgery or endovascular
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  surgery because myself and Dr.
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  Back, we both perform endovascular and open operations, and very complex ones.
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  And so, we offer the patient what they need with the least
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  morbidity and mortality that we can.
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  Dr. Martin R. Back:
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  And that being said, you know, Eric, we know that the endovascular versus
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  open interventions differ based upon pathologies at various locations,
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  but also by location in the aorta.
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  So for example, in the ascending aorta, we have very few
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  options endovascularly at all.
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  They're really more considered experimental currently
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  through some trials.
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  It's mostly open repairs of the ascending aorta.
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  The arch is now evolving to maybe more complex endovascular options, although
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  it certainly has not supplanted or replaced the need for open surgeries.
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  Down the rest of the thoracic aorta, there's a lot of endovascular repairs
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  that are now possible for pathologies and dissections and, aneurysms
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  that are probably maybe better and safer and get those equivalent
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  outcomes to the open operations.
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  When you come across the branches that go to the intestinal arteries and
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  the renal arteries, the endovascular repairs are much more complex.
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  And there are patients that have anatomy that doesn't lend itself to
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  even a complex endovascular repair, still requiring an open operation.
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  And you get down to the abdominal aorta below the kidney arteries, down
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  into the iliac arteries, certainly endovascular interventions have replaced
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  many of the open operations although open operations can certainly be done.
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  So, you know, we tailor our recommendations based upon what the
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  anatomy is, what the pathology is, and what locations of the aorta there are.
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  And then, relative to the patient's preoperative risk, their relative
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  frailty, what we anticipate with their potential recovery and their complication
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  rates, relative to underlying disease processes that, you know, can be cardiac,
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  pulmonary, renal, or other in nature.
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  So, there's a whole bunch of factors that go into these kind
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  of equations to make the best decisions for an individual patient.
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  Dr. Eric Jeng:
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  I think Dr.
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  Back started with this initially.
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  At the end of the day, an open operation will always be necessary for
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  something that endovascularly fails.
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  So, you need experts in the field like Dr.
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  Back and myself to be able to come in and replace an aorta open when
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  necessary, because sometimes these same stents they cause issues.
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  And there's nothing you can do to recover them.
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  And so, an open operation is the last stop at the end of the day
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  to be able to save the patient.
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  And that's really what it's all about, and it's always been what
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  it's about: the patients and being able to offer them the best option.
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  And open surgery happens to come into play when there's infections
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  related to the aorta or, for some reason, the endovascular options fail.
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  And so, open surgery, again, is sometimes the last resort.
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  But you need to have that expertise in your center when you're helping patients,
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  and it can't just be one or the other.
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  Dr. Martin R. Back:
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  There is an evolving problem in the country.
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  The number of open repairs of aortic pathology, especially aneurysms, is
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  falling because there's such predominant use of the endovascular techniques.
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  And with that happening, there's fewer and fewer places that have
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  familiarity and the technical abilities to perform open aortic operations.
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  So, it's falling upon tertiary centers regionalized referral patterns and centers
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  of excellence where there are surgeons who can still perform open operations.
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  That is a lot of our business here is referred from at least a three-state
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  area here in the southeast United States for complex scenarios that are
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  going to require an open operation that other folks out in the community
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  are just uncomfortable with.
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  Dr. Eric Jeng:
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  And I may have said this before, but at least last probably five to 10
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  years, we historically have been the second leading aortic center in the
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  country by surgical aortic volume, most recently performing about 1,000
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  aortic cases split between cardiac surgery and vascular surgery every year.
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  So, we are a high-volume center and high complexity center, and
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  we're open to helping people with less complex business also.
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  So, anybody that wants to send any of their patients that are less
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  complex, we're open to that too.
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  Melanie Cole, MS: Dr.
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  Back, I'd like you to expand for a second because we've done a previous podcast
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  about trainees and residents, and you mentioned the lack of ability to do open
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  with all the technology for endovascular.
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  Can you identify some of the barriers to that robust open
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  surgical training exposure?
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  When you think about the technology that's available today, whether it's robotics
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  or imaging techniques, there's so many different things going on in your field
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  which makes it so exciting, what would you like other providers to know, as Dr.
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  Jeng was saying about the high volume that you're doing, that in emergent
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  situations, the surgeon needs to be able to switch in a minute's notice.
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  Tell us a little bit about how that works in your aortic center of excellence.
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  Dr. Martin R. Back:
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  So, we have an active fellowship.
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  Fellows are in vascular surgery have already had five to six
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  years at least of general surgical training and then join a fellowship.
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  We are one of about 75 programs across the country that have fellowships.
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  There are other vascular surgery residency programs about equivalent numbers.
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  And frankly, you know, across most of the country, the finishing
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  residents or fellows have fairly low numbers of open aortic experiences.
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  And so, they may not have had enough experience to really feel
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  comfortable going out and practice and offering that, treatment.
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  And that has been a growing problem in the country.
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  Now, our fellows finish with gigantic numbers of open aortic exposures, and
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  I think we're training some of the best fellows to go out and try to maintain
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  that populace of really highly skilled vascular surgeons able to perform aortic
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  nterventions, both endovascular and open.
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  So, we can only fix our shop.
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  And we can't fix the shop of others, but it is a growing problem.
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  I'm not sure there's really currently similar problems in
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  cardiothoracic surgery, and I'll let Eric talk about that.
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  But it is a problem in vascular surgery.
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  Will there be a surgeon for me in 25 years when I form an aortic
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  aneurysm and I need it fixed open?
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  Is there anybody around who's going to be able to fix it safely?
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  Melanie Cole, MS: I would love to give you each a chance for a final thought, because
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  this is such an interesting discussion.
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  We could go on a long time, because there are so many avenues to the
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  complex work that you both are doing.
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  And so, Dr.
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  Jeng, what would you envision as the future of aortic
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  surgery in your ideal world?
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  Are there emerging trends, innovations that you feel will shape the
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  future of complex aortic surgery?
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  What would you like to see happening and what's coming down the pipeline?
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  Dr. Eric Jeng:
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  As I may have mentioned before, I am the program director for the
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  integrated residency program also.
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  And what we do is we integrate simulation as well as because of our
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  patient population status, we have a lot of open aortic surgeries, and
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  we train people on simulation runs as well as in real life on patients.
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  They operate on patients.
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  They contribute directly to the care of these patients.
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  And so, in our center, because we do so much aortic surgery, our residents are
• 16:59
  very comfortable operating on aortas.
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  And in fact, most of the nation, a cardiac surgeon mainly does coronary bypasses.
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  All of our residents blow out the numbers from a standpoint
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  of aortic cases that they log.
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  So, because we're strategically located a place with so many experts in the
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  different fields like vascular radiology, cardiac surgery, cardiac anesthesiology,
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  all these silos come together.
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  And so, because of that, we're exposing our residents to both the open and the
• 17:33
  endovascular approaches, and they see when things work and when things fail.
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  And so, they'll know in the future how to tailor their practices
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  and how to manage their patients.
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  And that's really the goal of our program, not only to help our community,
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  but to help train our residents and the future doctors so they can
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  help the communities in the future.
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  And in a program like this, we have both the open and the endovascular and
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  the robotic technologies to be able to train the surgeon of the future.
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  Melanie Cole, MS: Such an important point.
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  And Dr.
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  Back, last word to you.
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  What would you like other providers to take away from this multidisciplinary
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  information about the Aortic Disease Center at UF Health?
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  And what would you like them to know about working with patients in that
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  shared decision-making on open versus endovascular aortic disease when you're
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  thinking about that surgical planning?
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  Dr. Martin R. Back:
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  So, a couple final points.
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  I think the last area of really challenge is the ascending aorta in
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  terms of endovascular approaches.
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  It's highest flow greatest dynamic movement of the wall and the aortic valve.
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  And so, there are a lot of challenges.
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  And so, we are part of some clinical trials for new devices in the ascending
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  aorta, and I think it's kind of the last area of, really, endovascular
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  challenge, although there's certainly complex anatomies throughout the aorta.
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  The ascending aorta is one of those.
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  And, you know, finally, I'd like to make a pitch for our aortic symposium.
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  I think what we've tried to create in the last three years and now going on
• 19:09
  our fourth year is a unique program that highlights how cardiac surgeons and
• 19:17
  vascular surgeons can interact, treat complex aortic pathologies, and how to
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  perform some of these complex procedures.
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  This year, we're going to focus primarily on kind of how-to videos of, techniques
• 19:30
  for treating the aorta in various locations, both endovascular and open.
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  And I think this is a unique format that we've had running four years
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  now in that there are lots of endovascular symposiums across the
• 19:43
  country that are done in the vascular world, and it's all endo, endo, endo.
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  But this is unique that it's bringing together some combined
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  surgical and endovascular approaches, multidisciplinary decision-making,
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  and procedural performance.
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  I think there's a lot that can be taught and learned by
• 20:02
  folks that attend this meeting.
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  So, I'm making a pitch for attendance at this if you can
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  help spread the word for us.
• 20:09
  Dr. Eric Jeng:
• 20:09
  December 2026 in Orlando.
• 20:13
  Melanie Cole, MS: There you go.
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  I was going to ask you when the date was, so thank you for sharing that.
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  And thank you both for coming on.
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  It really is such an exciting time in your field.
• 20:22
  This was a fascinating discussion, thought leader roundtable.
• 20:26
  So interesting.
• 20:27
  Thank you both for joining us and sharing your incredible
• 20:30
  expertise for other providers.
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  To learn more about this and other healthcare topics at UF
• 20:35
  Health Shands Hospital, please visit innovation.ufhealth.org.
• 20:40
  And to listen to more podcasts from our experts, you can always
• 20:43
  visit ufhealth.org/medmatters.
• 20:46
  That concludes today's episode of UF Health MedEd Cast with
• 20:50
  UF Health Shands Hospital.
• 20:52
  I'm Melanie Cole.