Chapters Transcript Video Pushing the Limits of Hybrid Vascular Procedures Today we're exploring hybrid vast procedures and how they are transforming the treatment of complex vascular disease as advances in imaging, device technology and multidisciplinary collaboration continue to evolve, vascular surgeons now have more options than ever before to tailor treatments for patients who previously had limited or high risk therapeutic pathways. Together we'll discuss how hybrid approaches are changing clinical decision making, expanding treatment options for aortic and peripheral vascular disease, improving outcomes for complex patients, and shaping the future of vascular surgery. Welcome to Baptist Health Doctor Doc, a podcast built for innovation and collaboration by physicians for physicians. Hello, I'm Doctor Tom Wynn, system chief executive for Baptist Health, Heart and Vascular Care, Chair and professor of cardiovascular sciences at Florida International University. Joining me are two of our leading vascular specialists, Dr. Yun Lee, vascular and endovascular surgeon with Baptist Health, Heart and Vascular Care, and Doctor Ignacio Rua, vascular endovascular surgeon, also with Baptist Health, Heart and Vascular Care. Good morning. Thanks for joining us today. Thank you. Thank you for having us. For physicians who may not perform these, these procedures every day, how do you define hybrid vascular procedures and why has it become such an important treatment options for our patients? Hybrid vascular surgery means exactly what it says hybrid, so you combine open surgery with endovascular techniques. In the past, before revolution of endovascular surgery, the only surgical options for patients with significant arterial disease, aneurysmal disease, carotid disease was open surgery. But as endovascular procedures have come a long way and evolved and revolutionized our field, we have minimally invasive approaches now to treat these pathologies. However, there are still quite a few patients who don't fit in that category of just open or just endovascular, so hybrid vascular surgery allows us to do a component of the operation open. And then do the remainder endovascular to minimize the risk for patients, customize your surgical approaches and surgical planning, and give more options to patients who didn't have any options otherwise. And for those out there who might not understand the term endovascular, can you explain it for just, you know, maybe layman terms, what is endovascular? Layman terms, we go in through the arteries or veins using wires and catheters and either open up occlusions or place stent grafts to exclude aneurysms and um in carotid disease we put in stents. Doctor Roy, you know, about 10 years ago, or probably even more in the past, patients would end up having open procedures for a lot of these complex aortic pathologies. How is endovascular treatments really evolved in our patient management, managing, management process? Well, I gotta say, I think I have had a very, very lucky career because I started in the 80s when all we did was open. And then I, I basically got to witness the whole endovascular revolution, and it has just been wonderful to see this whole, uh, transformation and now we're moving on into another transformation where you have incredible open techniques now super evolved and the super, uh, uh, you know, incredible technologies endovascular, and now we're witnessing um. Basically a marriage of the two, what we call a hybrid approach, and that is just as, as Young mentioned, you know, is, is allowing us to do really major vascular reconstructions in the thoracic cavity, in the abdominal cavity, and not having to open. We use a hybrid approach using either the, the groins, the femoral arteries, using the carotids in the neck, which are much easier to expose and basically tackling these bigger procedures in the end without having to open. These major body cavities. Doctor Lee, when these patients come to see you all, how do you decide whether the patient gets a hybrid or an open surgical approach? So, I look at the patient as a whole. Age is not my only limitation because there are certain things called physiological age. So I also look at how functional the patient is, what is their quality of life right now, what are their medical comorbidities. Majority of the. Vascular surgery patients, they don't show up with just one problem they have cardiac issues they may be diabetic, they may have hypertension, hyperlipidemia, all these comorbidities that complicate the patient physiological status. So then you look at them and a lot of these patients fit under the category of being able to just undergo endovascular procedure. However, there are patients, for example, who have large aneurysms or aortic disease that would not do well with a big open operation, which can be very debilitating in the recovery. Um, but don't have the appropriate access, for example, their iliac arteries or the common febrile arteries are very diseased. They have a lot of plaque, they may be occluded or they may be too small. So in those scenarios there are a variety of hybrid approaches we can do. We can open up those arteries or we can do a small segment bypass to create a conduit to deliver these systems into the body and then do the more complex work minimally invasive. I thought it was pretty funny what you mentioned the physiologic age of the patient. Young and I recently took care of a. 97 year old gentleman, an attorney, a working attorney, drives himself with a big aneurysm and uh via minimally invasive techniques, he, he did fine. And then more recently, we took care of a 93 year old plumber who still works, carries his bag, and drives himself to his jobs. So it, it's true, it's not that uh age by number, it's age by physiology, but The fact that you have endovascular and hybrid techniques allows us to customize this for the patients. You bring up a really important point. I think in medicine we look a lot about the biological age, not the chronologic age. In the past, a 70, 89 year old, we definitely would not touch at all, but now. Especially with advances in endovascular techniques and even some open techniques, not uncommonly you all and us are are intervening in patients in their 90s and sometimes centenarians as well. Can you tell me, do, do all vascular surgeons do open and hybrid and do all most vascular programs do a combination of open and hybrid? No, definitely not. There's a. You know, there's, uh, you know, It's a problem in vascular surgery that no matter what, you're always gonna have to know how to do open, uh, major open vascular cases. The problem is that I was, if I had to guess, I would say 80, almost 85% of, let's say, aneurysmal disease is now managed endovascular. So we're having surgeons. Have less and less experience with open surgery. So, it's very important to in any program to have, uh, you know, be cognizant of that and any opportunity to, to learn open techniques that had that, that's, that has those skills have to be passed on. And so, it's, it's important that a program be able to do. Anything open, anything endovascular, and now in these same programs, do them in a hybrid uh manner. Actually, you were talking a little bit earlier about the decision making process. Can you comment on, on the collaboration? Who, who else makes the decision? How's collaboration with other specialties done? Um, who decides what's gonna, uh, be done, you know, the, the importance of collaboration and multi-specialty involvement with, with maybe the decision making process and maybe even with the procedure itself. So it's, I'll take aorta for an example because we have a significant aortic volume here at Miami Cardiovascular Institute. This just does not involve one specialty, you know, so you have the pre-procedural planning, um, we have vascular surgeons who are specialized and highly trained in this we have our interventional radiologists who also have are very highly trained and experienced in this so oftentimes because imaging interpretation requires a lot of finite expertise, it's good to collaborate so that you don't miss small nuances and that you're prepared for. Any situation during a case after that we also have to involve the fact that a lot of these patients need anesthesia and cardiac anesthesia because they're high cardiac risk patients so then we have the anesthesiology team involved if uh we're doing a long thoracic endograft, we want neurosurgeons involved for spinal drainage and after all of that you need good post procedural care which involves our intensive care unit. So it really does take a village to treat these patients appropriately to have the appropriate case planning. Some of these cases we have to think way outside the box that just whatever's available commercially is not our only options, and we have to use both hybrid techniques and advanced endovascular techniques, and that requires multitudes of. Specialties to put their brains together to come up with a customized comprehensive plan for the patient. We, we have a, um, aortic conference every Wednesday. In fact, just, just this, uh, just yesterday I had an amazing conference. We had 37 multidisciplinary physicians. I, I mean, we're talking from cardiothoracic, vascular surgery, interventional radiology, anesthesia. Vascular medicine, vascular in all we discussed every. Case that was, you know, in the works preoperatively. We discussed cases that have been completed. We discussed complications, how it could have been done better. It's really a, a, a really an entertaining conference, a conference where everybody learns and everybody collaborates, and it's, it's, I mean, it only can drive, uh, patient outcomes to be better. You both hint hinted at this a little bit, but if you can elaborate a little bit more, what makes the program at Baptist Health, Heart and Vascular a little bit different than, than other programs out there? I, I would tell you it, it has to be the, the level of collaboration. There's no, uh, you know, there's no real turf battles. Everything is, is, uh, resolved. Everybody is very collegial, and, um, it, you know, it's the, it's the patient that benefits, you know, if you have one person, you know, that only knows how to do it one way, guess what way that patient's gonna get? It's gonna get the whatever that person knows how to do, where you go to a place where there are many ways to do it. You have an open and, uh, you know, transparent conference. Everybody gives their pros and their cons, and together you arrive at a really good solution for really complex problems. I delete anything to add to that. I mean, I think also the diverse pathology receive, we receive patients from all over the world, so I think that alone. Gives us an opportunity to treat diseases a lot of other places don't. So to have that kind of multidisciplinary collaboration and cohesiveness is really important and it feels like we can tackle anything, you know, we can come up with a solution for every patient. Well, you mentioned age before we went into the 90s. Recently, we also went to the other extreme. We went to a 13 year old with a ruptured aorta. Well, we have partnerships with other hospitals and not uncommonly you all are going to our neighboring hospitals, Nicholas to, to help younger patients with aortic and, and vascular pathology. As well, and I, I'll also add that I've been involved in a lot of the, the multidisciplinary conferences and, and sometimes it's heated, sometimes it's controversial, which it should be, and I, and you know you're doing the right thing. If everyone there is agreeing on the same page, then, um, then it's a little bit too easy, but we're really bringing in experiences from everyone to bring in their perspective and then we walk out of the room unified and we do what's best for the patient. That's right. Can you both elaborate a little bit on, on technologies? What are some. Transformative technologies that we have now that have really allowed us to take care of these complex patients, these aortic and peripheral vascular disease patients, and maybe kind of look in the future. What's the future look like with transformative technologies that really kind of get us to the next level? What, what are we missing uh for the treatment of endovascular uh peripheral vascular disease? Well, I, I can, I can start, you know, I, I remember, you know, let's say a CT scan in the early 90s, you know, that really. Large cuts and, uh, you know, you'd get, uh, I don't know, 0.5 centimeter, even 1 centimeter cuts, and then you'd get into surgery and be kind of, there'd be a lot, always a lot of surprises. Now we have these incredible CT scanners, super fine cuts, super incredible resolution. Uh, I mean, you, you, you go into, let's say a, a carotid lesion, you know what the plaque's gonna look like. Is it gonna be soft? Is it gonna be hard as a rock? Is it gonna be ulcerated? And it's, it's just, and it's an incredible, incredible technology. So, I, I personally just fascinated with CT, but you can. So we have a multitude of other technologies as well. I mean, so starting with imaging, yes, not only do you have better resolution imaging and better quality imaging, you also have the ability to do 3D reconstruction, which allows you to. Come up with a device that works for the patient whether it's commercially available or if there's no commercially available devices available then we can modify these graphs. The physicians, the surgeons ourselves, we modify the graphs, but that can be only done with that kind of 3D modeling and precision imaging. We also have ways to fuse those images. You can take your 3D reconstructed image and fuse it onto the 2D imaging that we use in fluoroscopy. It's a way to reduce contrast use, reduce radiation use, all of which benefits the patient as well as the operators, so patients before with complex diseases that have renal failure or advanced. Kidney disease used to be labeled as oh we can't do anything because we're going to put you on dialysis however we have multiple different imaging modalities and technologies available to us and they're all available at Miami Cardiovascular Institute. That allows us to use these things to minimize the contrast use. Intravascular ultrasound is another imaging tool that allows us to minimize contrast use to characterize what's going inside within the vessel during the procedure, and all of these things just broadens our networks of patients that we can train or sorry, treat so. Well, you said the word train, you know, can you comment a little bit about training, you know, training, training staff, training future generations of vascular surgeons, endovascular specialists, maybe interventional radiologists. What's, what's that looking like here at Baptist? This is a very, another very exciting time period. I mean, now we have an incredible relationship with FIU. Have, uh, you know, medical students rotating on our service. We have, uh, interns, uh, residents, uh, rotating through our service. Very soon we're gonna have a vascular fellow, uh, and, and so that's just, uh, you know, Like I said, it's so important. You know, you get gather a lot of experience. It's important to pass a lot of your experiences, your skills on to the next generation. And so now Baptist is fully going to participate in that, and we're all very excited, very motivated to partake in that. And Doctor Lee, you'll be one of the program directors of the training program. So I know that you're probably also equally excited and doing a lot of work behind the scenes. Any additional comments? Yeah, definitely. I think having an academic training program set in um a tertiary institute is very important because it increases the level of diseases you can treat, the complexity. Um, research becomes in the forefront so then you can trial new devices to come up with better treatment approaches for the patients and in our scenario what we applied for a residency as well as a fellowship. So for example, when we have a vascular fellow, they will have already trained in another institution for their residency. So now you're bringing in more ideas from the outside and I think more diverse. Diversity and people's backgrounds just bring better options for the patients all around. Definitely we're talking a lot about the present with the present technologies available and and current training, but what does the future look like for treatments of aortic pathologies, peripheral vascular disease, um, whether it be technologies or structure of programs or what do you, what would you imagine? Young and I were just talking about this yesterday, the, the, there's now another revolution in robotics. You know, there's a new generation of, uh, robotic, um, companies that, uh, I know Baptist is, uh, participating in, and, in at least in the vascular, uh, sphere, we're just scratching the surface. We're both of us say we definitely wanna get involved, and so we've been talking with these companies. They've been very eager to get us trained. So we're, uh, I think that's gonna be a, a really, uh, incredible, uh, push in, uh, in this field. And robotics doesn't just involve like doing open surgery and now converting to robotic surgery, doing robotic bypasses, things like that. There's also endovascular robotics, you know, that is out there and now starting to enter the market and those kind of technology allows us for better accuracy with access to the vessel, more precision. Um, better ability to cross complicated lesions and so I just see our field is growing and growing. We can also include now you have artificial intelligence helping us characterize our disease, our dissections, or our aneurysms or our plaque and that and qualifying that data. So then you can be like oh I can anticipate this to happen to the patient in the future so we should treat it at this moment or we should come up with this kind of treatment plan to avoid any pitfalls so I just see our level of treatment just getting better and better. As we wrap up, I have a couple more questions. The first in the lines of training, but also academics and research. Can you let us know about what research projects are going on, uh, currently with, with the institute and, um, and then how, how, you know, you all are involved with it, how we're pushing the envelope with, with, uh, with innovation and research. 01 of our partners, uh, again, we were just discussing this yesterday, one of our partners, Doctor Michelle Taubman. Uh, spearheading an effort in, um, replacing the deep, uh, um, valves, uh, deep venous valves in the leg, which is a really big problem. The venous insufficiency is a big problem, uh, as a large percentage of the population, and it's always been very difficult for us to intervene. She's uh doing a a percutaneous valves replacement, and Baptist is going to participate in that and um uh in in that uh research, which is, you know, the entire country. We have another project going on that we're working with Florida International University um and the bioengineering and pathology department there um with our amputees. We're trying to research from our amputation specimens to see what the arterial plaques are in these patients so we can see what kind of arterial disease and what kind of plaque puts you at a higher risk of limb loss compared to other peripheral arterial disease so we have that going on as well. Lastly, if there's a community physician out there that wants to refer a patient to you all, uh, what's the best way of, of referring a patient to the institute? Uh, we have a direct number. I apologize that I don't know it by heart, but we do have a direct number. It's on the website, um, and something I would always like to mention, the earlier the referral, the better. I think we have a better treatment options, the earlier we, we get involved with the patients. I would also like to encourage that you know the telephone number no, not exactly, but I would also like to encourage the fact that just because another person said no to your patient's disease does not mean that is the end for that patient. If somebody else does not offer an option, it is always worth. A second opinion and and referring to us because again. As a mega institution and a coronary tertiary center we have so much resources and opportunities and expertise that smaller hospitals or institutions more rurally may not and so our motto is we don't say no, we try to find a solution and we try to find a creative solution when there's no. Obvious solution available and so just keep that in mind that if someone said no that's still OK refer it to us and we'll take a second look. I think that's so important because a lot of times people think that all medicine is treated equally, but there are a lot of different quality of medicine out there, different perspectives, and especially for high risk patients, uh, a lot of. Programs and places might be averse to treating those patients and it's good to get a second opinion and, and a lot of times those high risk patients end up here and we end up treating those patients. Uh, final, final comments and and thoughts, any, any final words, wisdom about the program here that you want to share with the audience? I think hybrid vascular surgery in general has allowed us to turn a no into a yes. So when one open just open is not an option due to how frail and sick the patient is, or if endovascular is not an option because there's no good access points, remember there's always the option of hybrid vascular surgery that we can minimize the open surgical part and create a pathway or an access way to do the minimum procedure minimally invasive. Yeah, no, it's just, again, this is a very exciting time to be in vascular surgery at the uh Baptist because Baptist is now embarking on more and more hybrid rooms. This and, you know, stepping into an operating room today is just. Incredible. It's the future. The future is very exciting. Today's discussion highlighted on how hybrid vascular procedures are expanding treatment options for patients with complex vascular disease through the thoughtful integration of open surgical and endovascular techniques. We explore the importance of multidisciplinary collaboration, advances in imaging and device technology, and the evolving role of hybrid approaches in treating aortic disease, peripheral vascular disease, and other challenging conditions. These innovations are helping physicians deliver more personalized care while improving outcomes for patients who previously may have had limited treatment options. For our listeners to learn more about Baptist Health, heart and vascular care, and our comprehensive vascular services, visit baptisthealth.net. Thank you Doctor Lee, Doctor Wu for sharing your perspective. Thank you for taking care of that patient earlier today. We're very fortunate to have you here to take care of our, our community. Thank you. Thank you. Thank you very much. To find out more about the topics covered on BaptistHealth.to doc, please visit physicianresources.baptisthealth.net. Created by
