“I feel good, doctor. It doesn’t even look like I’ve had surgery. I’m ready to go home! – Mr. Silva tells me (fictitious name)standing, moving his legs and pointing to his groin, where two small bandages reveal that something invasive actually happened about 48 hours earlier.
Silva is 74 years old and, like many his age, suffers from an aortic aneurysm, an insidious cardiovascular disease, little publicized, but with potentially devastating consequences. The aorta is the largest artery in our body, responsible for distributing blood to different organs and tissues. In genetically susceptible people, due to risk factors such as smoking, high blood pressure and high cholesterol, the aorta can dilate its walls, thus forming an aneurysm. This disease rarely produces chronic symptoms, but can be suddenly complicated by a rupture and internal bleeding, which is often fatal.
The existence of specific ultrasound screenings, as well as the generalization of several other imaging tests, have led to greater diagnostic capacity. As a result, more timely treatment is also required, which may involve surgical repair in cases where the risk of rupture is estimated to be significant.
In this field of surgery, as in many others, the advances have been extraordinary and worthy of the imagination of the most brilliant minds in science fiction: not even Arthur C. Clarke would be able to foresee what has developed in this field. in recent years. The last three decades… and the future. The next one could be even more spectacular. Technological and technical advances are many and represent an intricate symbiosis between researchers, engineers, scientists and doctors.
Let’s see: in the field of diagnosis, today we have a very high resolution capacity: Marie Curie would be proud! – and manipulation of the radiological image. This allows not only the identification of pathology, but also the detailed evaluation of anatomy and surgical planning, using sophisticated workstations equipped with advanced software that includes artificial intelligence, which is increasingly useful and ubiquitous. Moving on to the operating room, we have the fluoroscopy-guided intervention, by fusing intraoperative images obtained using image intensifiers with previously performed CT scans, among other possibilities.
As vascular anatomy is quite variable, implantable materials to exclude aortic aneurysms must be selected to the millimeter for a specific patient (in our case, Mr. Silva). Depending on the complexity and extension, it may be necessary to preserve arterial branches essential for life – such as the hepatic, intestinal or renal arteries – and adapt vascular grafts to curvatures or changes in caliber. Today it is possible to commission complete customization, like a refined tailor, producing a prosthesis with the exact characteristics of its recipient. It is one of the faces of precision medicine.
It is even possible, using 3D printers, to insert an exact replica of the created graft into a printout of the recipient’s aorta, as a preliminary test of its effectiveness, or to “feed” a digital simulator with CT data and perform the procedure in question on a high-fidelity simulation, before the real case.
Also in the operating room many things have changed. Teams dressed in radiation protective clothing and, in the center, a sophisticated fluoroscopy device with multiple buttons and screens, report what will happen next. Instead of extensive and complex anatomical exposure – “maximal invasive surgery,” as an Italian colleague, an expert in open aortic surgery, called it – all of this is now done through millimeter holes, typically in the femoral arteries, at the level inguinal. . This mini-invasiveness has obvious advantages in terms of risk, physiological impact, and recovery.
This type of operation is called endovascular and is the art of building the vessel inside the bottle, through the neck. This is only possible thanks to a remarkable evolution of materials, techniques and knowledge that shows no signs of slowing down. On the contrary, we are increasingly moving towards smaller, safer, more biocompatible and more durable products. When I talk to Mr. Silva on Wednesday morning, dressed “in civilian clothes” and ready to return home, I imagine what stage of his recovery he would be in if, two days earlier, he had undergone open surgery on his extensive aneurysm; Still in an intensive care bed. Fortunately, you will never notice this difference.
It is not all advantages: there are still limitations related to the durability of the materials, their ability to adapt to the degeneration of human tissues, such as the risk of infection, among others. And there will still be patients for whom “maximal invasive surgery” remains the best option. But until a new disruptive technology emerges (a pill, perhaps?), the endovascular solution has undeniable advantages for most patients and has expanded the spectrum of treatment to those who could not afford such an extensive operation. It is an example of human ingenuity put at the service of the population’s health.
Frederico Bastos Gonçalves is a consultant of Angiology and Vascular Surgery at the Santa Marta Hospital, coordinator of Angiology and Vascular Surgery at the CUF Tejo Hospital and visiting assistant professor at NOVA Medical School. He is co-author of the European Society for Vascular Surgery guidelines for the treatment of aortic aneurysms, published in 2024.
Arterial is a section of the Observer dedicated exclusively to topics related to cerebrovascular diseases. It results from a partnership with Novartis and has the collaboration of the Association to Support Patients with Heart Failure, the Portuguese Cardiology Foundation, Portugal AVC, the Portuguese Stroke Society, the Portuguese Atherosclerosis Society and the Portuguese Society of Cardiology. It is completely independent editorial content.
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Source: Observadora
