ABHI Guest Blogs with Dr Trevor Cleveland: The Advancements of Minimally Invasive Care
In our busy world of medical care, what are the areas that have really seen amazing change? It’s got to be drugs and devices.
In my area, Interventional Radiology (Image-guided surgery), technology has often made treatments that used to be open operations, that carried significant mortality and morbidity, along with long recovery times, into day case minimally invasive solutions.
Devices, delivered using image guided techniques, have life-changing and life-saving effects across a number of clinical areas, including sepsis management, arrest of bleeding (in trauma and other scenarios), women’s health, and cancer to name a few.
In the arena of vascular diseases, the technologies that we now take for granted, have only really been developed over the past 10-15 years.
In a world of ever increasing numbers of people who have diabetes or renal failure, and many who still smoke, the incidence of arterial disease continues to climb. The first balloon angioplasty was described in 1976, but it wasn’t really until the turn of the century that there was any alternative to “simple” balloons. Since then we have seen the early stents, which have been developed and improved to fit and suit all areas of the body including the iliac, femoral and tibial vessels in the legs, renal arteries, carotids and even the cerebral circulation. In addition, balloons have been modified to take the high pressures needed for reopening dialysis fistulas, can cut fibrous tissue (cutting/scoring balloons) and are now coated with drugs (drug eluting balloons), used to try to overcome the problem of restenosis. Stents too can be coated with similar drugs, with the intention of reducing late failure due to re-narrowing.
Metal stents can also be made with a fabric covering, making them into stent-grafts. These have revolutionised the treatment options for aneurysms (abdominal and thoracic aortic, and popliteal). They can also be modified to place side branches into vessels such as the renal and mesenteric arteries, allowing the grafts to treat aneurysms involving these important branches (fenestrated grafts). They also have a life saving role in the treatment of traumatic rupture.
The other major scenario where technology has made the world a very different place is in the treatment of bleeding and cancer therapy. The development of a huge variety of catheters, both large and small, has made arteries accessible using local anesthetic, usually from the femoral artery. These have been used in conjunction with a variety of devices (embolisation coils, plugs and particles) to rapidly and effectively stop bleeding, often with the retention of organ function, rather than removal (e.g. the spleen, liver segments, kidneys, colon and other vascular beds). Not only can these be used with the intention of cutting off the blood supply to a specific area, they can also be used to infarct tumours and to precisely deliver chemotherapy or radiotherapy, which can be bound to particles prior to injection.
The most recent exciting advance in the vascular arena is mechanical thrombectomy for stroke. In this technique either a small catheter or stent-retriever, is used to remove a clot that is causing a stroke. Thrombolysis has made a major advance in stroke management (like it did with coronary events). However, in those who fail to respond rapidly or have a contraindication, have an anatomically suitable clot burden, and are treated quickly, this has the potential to make significant improvements in outcome for 8,000 people or more per year in England alone.
When one looks back over the last decade, Interventional Radiology in general, and endovascular procedures in particular, have made enormous strides, the majority of which simply would not be possible without the technologies being put into our hands to offer minimally invasive care to our patients on a daily basis.
Dr Trevor Cleveland is a Consultant Vascular Radiologist at Sheffield Teaching Hospital. An honorary Senior Lecturer at the University of Sheffield, he is also President of the British Society of Interventional Radiology.