ENDOVASCULAR SURGERY IN INDONESIA

Sahal Fatah
Diponegoro University
KARIADI HOSPITAL

Endovascular therapy is the manipulation of

pathology by an intraluminal approach
History of endovascular therapy can be divided
into two 30-year periods.

1929

1960

2014

Era of diagnostics

Era of therapeutics

Cardiac and vascular diagnostic

procedures were rapidly developed
(Table 1.1)

Development of interventional
modalities such as embolectomy,
angioplasty, and atherectomy
(Table 1.2)

Evolution of Endovascular Therapy: Diagnostics and

Therapeutics
Thomas J. Fogarty and Amitava Biswas

Evolution of Endovascular
Diagnostics and Therapeutics

Evolution of Endovascular Therapy:

Diagnostics and Therapeutics
Thomas J. Fogarty and Amitava Biswas

Era of Diagnostics
(19291959)
The surgeon Renaldo Dos Santos,
breakthrough applied to the extremities and to
develop arteriography and aortography
Forssmann should be possible to insert a
catheter into the right side of the heart through a
venous channel and thereby:

monitor cardiac pressures

obtain blood for analysis, and
administer therapeutic agents

Renaldo Dos Santos, MD,

Pioneer surgeon and original
developer of diagnostic arterial
visualization techniques and
technologies

Werner Forssmann, MD,

Physician credited with developing
endovascular diagnostics by
demonstrating cardiac assessment
using catheter

Werner Forssmann inserting a

catheter into his antecubital vein
1956 Nobel Prize in Medicine

Andr Frdric Cournand

A Surgeons who is known for cardio
catheterization
Nobel Prize in Physiology or Medicine
the Anders Retzius Silver Medal of the
Swedish Society for Internal Medicine

Sven Ivar Seldinger

A radiologist from Sweden. He
introduced technique to obtain safe
access to blood vessels and other
hollow organs

Era of Therapeutics
(19601990)
EmbolectomyFogarty The earliest disease
entity to be approached intraluminally was
embolic occlusion.
Balloon AngioplastyDotter/Grntzig used
a balloon catheter made by Fogarty to
expansion of the balloon caused an increase
in the lumen diameter (iliac stenosis).
AtherectomySimpson developed the idea
of mechanically removing atheroma from
vessels lumen (atherectomy).

Dr. Thomas J. Fogarty

An American CardioVascular surgeon
inventor of the embolectomy catheter
for removing an embolus, or blood clot

Charles Theodore Dotter

Radiologist The Father of
Intervention. Described angioplasty
in 1964

Andreas Roland Grntzig

A German Cardiologist who first
developed successful balloon
angioplasty for expanding lumens of
narrowed arteries

Julio Palmaz
Doctor of vascular radiology. He
got the idea for his stent after
listening to a lecture by Gruentzig
at a conference in New Orleans in
1978.

John B. Simpson, MD,

Cardiologist and innovator
of catheter-mediated techniques for
treating coronary artery
atherosclerosis

Juan C. Parodi, MD,

Vascular surgeon and designer
who advanced the clinical
techniques and applications for the
transluminally placed endovascular
endograft

Whose responsibility is
Endovascular?

?
?

??

Future Developments

The users of the new technology are often

shared by multiple specialties. In the
endovascular field we have :
Cardiologists
Cardiothoracic and Vascular Surgeons
Vascular surgeons
Interventional radiologists

All threating the same diseases and pathology with

the same or different techniques and instruments.

Endovascular Practice in AsiaPacific

Consists of countries with wide diversities in:

Population
Ethnicity
Language
Clinical practice

The incidence and detection rates of occlusive and

aneurysmal diseases are on the rise.
The growth of endovascular surgery, depend on:
Device availability
Regulations
Skills

Stephen W.K. Cheng

Professor, Department of Surgery, Chief, Division of Vascular Surgery, Queen Mary Hospital, The University of Hong Kong,
Hong Kong, China

Asia
With modernization and changing dietary habits,
we are witnessing an increase in the incidence
of arterial pathologies
The development of endovascular surgery in
Asia is slow, and most countries have only a
small group of dedicated vascular surgeons.
Peripheral vascular surgery is often practiced
within the domain of general or cardiac surgery.

China
1.3 Billion
Population

Chinese
Vascular Society

Increasing trend of
specialization in
vascular surgery

Vascular Surgeons

General Surgeons

Vascular surgery is not a popular specialty, but there are

large individual hospitals and units in major cities
dedicated to cardiovascular and peripheral vascular work.

> 2,000 cases

are performed annually

in

200 regional
centers

EVAR TEVAR is largely carried out by surgeons in

operating theatres.
Local training institutions and facilities are very limited
Many vascular surgeons have additional experience in
overseas centers: United States, Australia, or Europe
fellowships or short-term course

Japan

80 medical
education centers

4 vascular
surgery professors

2,000 members
of Vascular Surgeons

10,000 AAA repairs

were done annually

Aneurysm repair (EVAR-TEVAR) and lower limb

procedure majority are performed by cardiothoracic
surgeons (over 80%)
Open surgery is largely done by cardiac surgeons, while
carotid disease is managed by neurosurgeons

Korea
Similar to Japan, there are no large numbers
of vascular surgeons
Interventional radiologists have traditionally
dominated peripheral endovascular work.
300 EVARs and 100 TEVARs have been
performed annually

Hong Kong

Vascular surgery practice

is mainly confined to
two university hospitals

and the rest are performed

by general surgeons.

Affordable health care

for all citizens are provided

but expensive devices

were not included;
i.e. endografts and stents.

In general, peripheral endovascular surgery is still not

popular due to reluctance of the patients to undergo
intervention and to pay for expensive devices.
Endovascular stent graft remained at this time largely
in the hands of surgeons, working in operating room
setting either individually or in cooperation with
radiologists.

Taiwan

Vascular surgery only gained recognition as a specialty in

the mid-2000s, when the Taiwan Society for Vascular
Surgery was established.
Prior to this endovascular work was largely in the hands of
cardiologists.
There has been a significant volume of carotid and
vertebral angioplasty and stenting done by the Division of
Cardiology at the National University of Taiwan Hospital.
EVAR development was late in Taiwan due to government
regulations mandating a FDA-type trial before any devices
can be registered for use.

Thailand
Endovascular surgery has also proliferated
significantly in Thailand in the last few years.
Initially supported and reimbursed by the
government, covering 80% of device costs, there has
been a rapid growth of endovascular stent grafts, but
at significant expenses to the government

Malaysia
EVAR and other endovascular surgery is limited to a
very few private vascular surgeons who have the
facilities and the patients to afford the devices.
Currently this remains a very small market.

India

1.1 Billion
of population

70 vascular surgeons
in 2008

10 out of 24
medical schools
have vascular surgery unit

7 centers
have training program for
12 vascular trainees annually

Vascular surgery is still in its developing phase

There are about 5,000 arterial reconstructions per
year, and most of the work is done by cardiac and
general surgeons.

Indonesia
240 Million
of population

Indonesia has only one vascular surgery

program in Jakarta.

and had two cardiovascular thoracic surgery

program in Jakarta and Surabaya.

Indonesia
Hospitals

TEVAR and EVAR*

RSPJN Harapan Kita Jakarta

Cardiologist
Thoracic Cardio-Vascular

RSUPN Cipto
Mangunkusumo Jakarta

Vascular Surgery
Cardiovascular Consultan

RSUP dr Kariadi Semarang

Thoracic Cardio-Vascular
Surgery
Intervention Radiology

RSUD dr Soetomo Surabaya

Cardiologist
Intervention Radiology

RSUD Sanglah Denpasar

Thoracic Cardio-Vascular
Surgery

RSUD Dr. Moewardi Solo

Thoracic Cardio-Vascular
Surgery

RSUD Dr. Zainal Abidin

Aceh

Thoracic Cardio-Vascular
Surgery

* Thoracic-Abdominal Aneurism and Dissecting

** Arteriography, PTA, Stenting

Peripheral
endovascular
diagnostic and
treatment **

Advantages and Disadvantages

Endovascular

Advantages
Less invasive
Less hospital length of stay
Less morbidity and mortality

Disadvantages
More expensive

Indication of Endovascular

CHRONIC LIMB ISCHEMIA : Arteriografi, PTA Stent graft

ACUTE LOWER LIMB ISCHEMIA : Thrombolysis , Thromboembolectomy
CAROTID AND VERTEBRAL DISEASE : Angioplasty and stenting
VISCERAL ARTERY OCCLUSIVE DISEASE : Angioplasty and Stenting
THORACIC and ABDOMINAL AORTA : ANEURYSMS AND DISSECTIONS
VISCERAL AND PERIPHERAL ANEURYSMS : Endovascular grafting
VASCULAR MALFORMATIONS : Embolization, coiling
VASCULAR TRAUMA : Arteriografi, Embolization
VENOUS DISEASE : IVC filter, Venoplasty, stenting
ARTERIOVENOUS ACCESS

Complication

Access Site Complications

Hematoma and False Aneurysms 2-6%
Arteriovenous Fistula 0,1-0,2%
Access Vessel Thrombosis

Target Site Complications

Acute Closure 1-7%
Rupture 0,6-1,2%
Stent Infection

Distal Complications
Embolization
Cholesterol Embolization

Endovascular therapy is a multidisciplinary

field
involving contributions from surgeons,
cardiologists
radiologists, physicists, and engineers.

Endovascular is the
responsibility of the
Cardiothoracic and Vascular Surgeon
Vascular Surgeon
Cardiologist
Radiologist

DO NOT BLAME EACH OTHERS