Shang Loh, MD, is chief of vascular surgery and endovascular therapy at Penn Presbyterian Medical Center in Philadelphia and professor of clinical surgery at the University of Pennsylvania. Ahead of the Embolization for Vascular Surgeons: Techniques, Tips and Tricks lunch session Wednesday (12:30–1:30pm in Maryland A), he spoke to VS@VAM about the embolization-related challenges vascular surgeons can come up against in their practice, and how cross-specialty partnership is key for maximizing the quality of this type of therapy.
VS@VAM: Would you be able to outline the embolization procedures that fall into the vascular surgery wheelhouse?
SL: I don’t think that any embolization procedure is necessarily out of the wheelhouse for a vascular surgeon if they have the desire to learn the skills. However, traditionally, the majority of embolization work falls into the following categories: primary treatment of aneurysms such as splenic, mesenteric, and pseudoaneurysms; adjuncts to aortic aneurysm treatment including embolization of branch vessels and accessory vessels; endoleak treatment; chronic dissection management; venous disease; arteriovenous (AV) or venous malformations; trauma and bleeding.
VS@VAM: What does your vascular surgery practice focus around, particularly from an embolization perspective?
SL: My practice involves all areas of vascular surgery but primarily on the arterial side. My practice is mostly focused on aortic diseases but I also do aneurysm work in other areas, as well as peripheral and cerebrovascular work. I perform all my own embolizations except for venous disease and AV/venous malformations. Trauma is handled mostly by interventional radiology (IR) at our hospital but I will perform my own trauma embolizations if I am already involved in their care. The majority of my embolization work revolves around adjunct treatments for aortic aneurysms (such as branch or accessory vessel occlusion), embolization for type II endoleaks, embolizations for aortic dissections, and embolization as primary treatment for other peripheral aneurysms. I also teach courses, along with Dr. Darren Schneider, on various techniques for embolizations of type II endoleaks and speak about embolization techniques.
VS@VAM: What are some of the challenges that vascular surgeons may face when doing these procedures?
SL: One of the main challenges is acquiring the proper skill set. This is heavily dependant on prior training with older surgeons not necessarily having been trained in this. As a corollary, surgeons starting out in the embolization realm may find challenges in getting the proper inventory in place— and having the right imaging equipment. However, the focus of sessions such as Wednesday’s is to help bridge that gap and allow them to incorporate these elements into their practice if they desire. The other main challenge is that other specialties, such as interventional radiology, perform similar procedures. It is critically important to discuss this from a multidisciplinary perspective in order to determine everyone’s role in treating the different types of patients. I strongly believe in cross-specialty participation in embolization and believe a partnership provides the best care for patients.
VS@VAM: In your experience, what does this cross-disciplinary approach to caring for patients who require an embolization entail?
SL: As I previously mentioned, I strongly believe in a partnership with a cross-specialty approach to embolization. This skill set is present in a few different specialties. The most important step is to have representation from all the specialties at the table and to formally outline areas that are treated by one specialty versus areas treated by more than one. This can also include how patients will be referred. It is also important to decide how the emergency cases will be handled and whether there should be a shared call schedule for these. This is most important in the trauma setting. This removes any confusion when referring patients and when patients need emergent treatment.