Minimally Invasive Techniques Treat CTO
Advanced techniques and technology now allow surgeons to use minimally invasive revascularization to treat chronic total occlusions (CTO) that result from peripheral artery disease (PAD).
"We usually see patients because their legs hurt when they walk, or they have sores, ulcers or wounds on their feet that are not healing," says Scott Kujath, MD, FACS, a vascular surgeon since 2001 with Kansas City Vascular, P.C., on the North Kansas City Hospital campus.
During evaluation of claudication or a wound that is not healing, the PCP or wound-care physician conducts noninvasive arterial studies such as ankle-brachial indices. "Patients are usually referred to our practice when these studies show a blood pressure reading at the ankle that is lower than in the arm," Dr. Kujath said.
"That’s a sign of blockages in the leg. If there is a simple narrowing of the artery, it is usually moderately simple to fix with balloon angioplasty, stenting or athorectomy – or a combination of those," he explained. "These are the same techniques we’ve used for the past 15 or 20 years, so it’s pretty straightforward. But if the artery is completely occluded, it takes more work to get through it to make sure we have a conduit – an artery – that is relatively normal before and after the occlusion."
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Advances in recanalization CTO catheters now make it possible for Dr. Kujath to do minimally invasive surgery even in these more serious cases. The catheters use mechanical impact to create micro-channels through the solid CTO surface in the vessel’s central lumen. "With this technique we can reopen the artery and re-establish normal flow," Dr. Kujath noted.
Recovery is much faster than with traditional surgery that requires three to seven days in the hospital, major incisions in the legs and six to eight weeks of recuperation. "With minimally invasive techniques patients are able to walk normally and go home the same day," Dr. Kujath says. "After three days there are no restrictions, and they can get back to their normal activities."
The prognosis for many patients is excellent. "If they’re not smoking, treatment can last several years, and in some patients forever," he said. "But if they continue to smoke tobacco, retreatment may be necessary in less than two years. In cases of severely progressive disease, they are in danger of losing their limbs."
PAD must be treated to prevent not only loss of limbs but heart attacks and strokes. "Approximately 8 million people in the United States have PAD," the Centers for Disease Control reports. Aging increases the risk, especially for men. The Vascular Disease Foundation points out, "One in three people age 70 or older has PAD."
Technology Training Needed
"The technology has been evolving over the past 10 years, and the more advanced techniques to treat CTO have been available for the past two to four years," Dr. Kujath added. "But just having the technology available is not enough. Physicians must also have the technical skills to use it. Nationally, in the last two years there’s been improvement in education and understanding of how to use these devices and how to open the CTO with minimally invasive techniques instead of bypass or open surgery."
To help other physicians in Kansas City and out of state gain the expertise needed, he mentors peers in the surgery suite on techniques using recanalization catheters for minimally invasive CTO surgery. Karl Stark, MD, FACS, a vascular surgeon with Kansas City Vascular and director of the Wound Healing Center at North Kansas City Hospital also conducts training.
Kansas City Vascular’s surgeons do hundreds of revascularization of the lower extremities at North Kansas City Hospital every year, including dozens of CTO. The practice also participates in clinical trials to ensure that patients get the best possible care.
Scott Kujath, MD, FACS
Dr. Kujath received his medical degree from University of Missouri-Kansas City School of Medicine, and completed a residency in general surgery at University of Missouri-Kansas City. He is a Fellow of the American College of Surgeons with expertise in vascular surgery and treatment of chronic wounds. He serves on the medical executive committee, operating room subcommittee, surgery advisory committee (which he currently chairs) and carotid stenting subcommittee at North Kansas City Hospital. He also serves on the boards of directors of the Kansas City Surgical Society and the Metropolitan Medical Society.
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