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Minimally Invasive Technology

Operations involving the great vessels of the body have long carried a “mystique” both for surgeons and anesthesiologists due to the historically high mortality associated with these types of procedures. Aneurysmal disease was first described by the roman physician Galen (AD 129200) in the second century. Also in the second century, the Greek surgeon Antyllus described a surgical approach to repairing these “balloon-like dilations” of arteries. The Antyllus method involved ligation of the vessel above and below the aneurysm, followed by incising the aneurysm to evacuate the clot. This was carried out primarily on popliteal aneurysms, and due to lack of anesthesia and antiseptics, the mortality was rather high. Nonetheless, this technique became the standard surgical approach for centuries. Centuries later, Dr John Hunter (1728-1793) is credited with the proximal ligation of a popliteal aneurysm to treat this disease process—relying on collateral circulation to support the distal limb. Dr Astley Cooper, a student of Dr Hunter, took this concept further and attempted the first repair of an iliac aneurysm. The patient did not survive, but the technique was later applied successfully by Dr Matas in 1923, and further refined to restore blood flow within the vessel itself—the “reconstructive endoaneurysmorrhaphy.” There have been many prominent figures in the development of aortic surgery that built on these early endeavors, but 2 figures in the 1960s—Dr Michael Debakey and Dr Denton Cooley—truly revolutionized open aneurysm repair, introducing much of the cardiopulmonary bypass techniques used today. The next phase in history of both vascular and cardiac surgery may well be the minimally invasive revolution that has taken hold in recent years. New techniques are being developed that go beyond the percutaneous coronary interventions, but now extend to thoracic aneurysm repair, aortic valve repair, and aortic dissection management. In addition, minimally invasive approaches to mitral valve disease are showing promise. I plan to present information covering these exact topics in this and future issues. This quarter, we have 2 extensive reviews focusing on the use of minimally invasive techniques in aortic surgery. The first, titled “Neurologic Complications of Thoracic Endovascular Aortic Repair” by Drs Brant, Wang, Low and Cheung from the University of Pennsylvania, focuses on thoracic endovascular repair, with a particular look at methods to monitor and reduce neurologic complications. The second article by Drs Jazaeri, Gupta, Ronchon, and Reece from the University of Colorado, focuses on aortic dissection pathology and the utility of endovascular techniques to treat this difficult clinical problem. Each of these articles employs a multidisciplinary team of authors to provide a wide clinical view for these challenging cases. Our Roundtable discussion for this quarter involves an expert panel discussing clinical approaches to both