Seminars in vascular surgery
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The rapid evolution of catheter-based technologies during the last 5 years has created a critical need for development of effective resident level and postgraduate education programs in both open and endovascular techniques and associated cognitive and clinical skills. Currently, significant variability exists in endovascular training formats and in the number of endovascular procedures performed during the course of a graduate or postgraduate program. Little information on the quality of these programs exists and in the subsequent practice patterns of the trainees. This report reviews recommended credentialing requirements, training paradigms, and the growing experience of vascular surgical trainees since 2000.
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Within the past 5 years, radiofrequency ablation and endovenous laser treatment have been introduced as important new endovenous ablative techniques for the minimally invasive treatment of superficial venous reflux and varicose veins. Although sclerotherapy has been a well-established technique for spider telangectasia, recent reports have documented that administration of aerated or foamed sclerosants provides an excellent cost-effective option for treatment of varicose veins. This report reviews the indications for these minimally invasive techniques, the technical aspects of these approaches, and describes in detail the short and long-term success rates. To date, results of minimally invasive therapies are equivalent to or surpass those of surgical vein stripping, while offering dramatically reduced recovery time and complication rates.
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Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms has been challenged by a number of groups, and the shortcomings of this procedure have been documented in the scientific literature. However, patients and physicians continue to pursue this procedure as a viable means of treating abdominal aortic aneurysms. ⋯ These improvements and accomplishments have also been chronicled in the literature. This review looks at the successes of EVAR, based on both US Food and Drug Administration trials and independent studies comparing conventional open repair and endovascular repair.
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The role of carotid endarterectomy in the prevention of stroke was validated by two randomized clinical trials, the North American Symptomatic Carotid Endarterectomy (NASCET) and the Asymptomatic Carotid Atherosclerosis Study (ACAS). However, these trials excluded patients at high risk for perioperative stroke and other morbidity, raising concerns for the applicability of the trial results to the general population. ⋯ High-risk patients are more common than generally believed and their outcomes may be the same with carotid endarterectomy as it is with carotid stenting. Truly "high-risk" patients with shortened life expectancy are best served with no intervention.