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EDITORIAL
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 153-155

Endovascular therapy in vascular surgery - how relevant is it to India?


Senior Consultant, Vascular Surgery Unit, Division of Surgery, Sultan Qaboos University Hospital, Muscat, Oman

Date of Submission25-Mar-2020
Date of Decision28-Mar-2020
Date of Acceptance02-Apr-2020
Date of Web Publication10-Jul-2020

Correspondence Address:
Dr. Edwin Stephen
Senior Consulant, Vascular Surgery Unit, Division of Surgery, Sultan Qaboos University Hospital, Al–Khoud, Muscat
Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_44_20

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  Abstract 


The world has seen a sea of change in options available to patient's with peripheral vascular disease be it venous or arterial pathology – when it comes to endovascular therapy over the past decade. Intervention in most cases can be carried out as outpatient, day-care, or short stay in hospital. However, all this comes at a price. This article looks at the relevance of “The Endovascular revolution” in the context of Indian health care.

Keywords: Endovascular, India, revolution, therapy, vascular


How to cite this article:
Stephen E. Endovascular therapy in vascular surgery - how relevant is it to India?. Curr Med Issues 2020;18:153-5

How to cite this URL:
Stephen E. Endovascular therapy in vascular surgery - how relevant is it to India?. Curr Med Issues [serial online] 2020 [cited 2020 Oct 30];18:153-5. Available from: https://www.cmijournal.org/text.asp?2020/18/3/153/289418




  Introduction Top


India, as a country, has led the way in many a health revolution and discovery. However, when it comes to the “endovascular revolution” the country was about a decade behind but has caught up quite rapidly.

Evidence of this was seen at the “Endovascular Live 2020” meeting at New Delhi in February this year, which saw a live demonstration of 82 endovascular cases over a 2½ day period from centers across India. This was far more than the number of live cases showcased at the Mecca of endovascular meetings – The Leipzig interventional course. India can boost of its “in-house” peripheral stent design and manufacturing, in Delhi.[1]

As clinicians, we see the entire spectrum of vascular disease/pathology – Congenital/traumatic/iatrogenic vascular malformations, arterial, venous, and lymphatic. All of these have the option of being treated by open surgery, endovascular means, or a combination of both.

Having said all this, how relevant is this change to the common man? What can be done to ensure the benefit of endovascular therapy (EVT) reaches the masses?

This write up will look at these questions and suggest mechanisms to address them.


  Burden of Peripheral Vascular Disease in India Top


China is the most populous country in the world, followed only by India. The population of India has grown from 1.366 billion in 2019 to 1.380 billion (717 million males and 663 million females) in 2020. India's world surface area is 2.4% and it houses 17.8% of the world population.[2]

India has about 60 million people suffering from diabetes, and almost half of this number is undertreated or undiagnosed. Our country is among the top ten countries in the world for its diabetic population.[2] Obesity is also on the rise, especially in the urban areas among the population in the high socioeconomic strata. Reports state that >135 million Indians are affected by obesity.[3] These two comorbidities contribute significantly to the burden of vascular pathology in the nation.

Unnikrishnan et al.[4] stated that the burden of aortic aneurysms (T/AAA) is rising and 40% of these are incidentally detected. The SAGE Group state that the prevalence of peripheral arterial disease (PAD) is about 41–54 million, with an estimated 4.2–6.2 million patients of critical limb ischemia.[5] A cross-sectional survey conducted in rural and urban Vellore city on the prevalence of PAD among 5429 adults aged between 30 and 64 years, found that the prevalence was higher in urban (6.9/1000) versus rural areas (3.8/1000).[6]

Varicose veins affect 30% of India's adult population and over ten million new cases get added each year.[7] These patients constitute the bulk of patients seen in a vascular outpatient department.[8],[9]


  Why Should Endovascular Therapy Be The first Option? Top


Frank Veith, vascular surgeon, professor, and vice-chairman of surgery at Montefiore Medical Center of Albert Einstein College of Medicine, in his presidential speech (Society of Vascular Surgery, USA) decades ago said about vascular surgery-” specialties are such as species, they must evolve or go extinct.”[10] Two pioneers, Juan Parodi and Julio Palmaz, Argentinians, a vascular surgeon and interventional radiologist respectively, by deploying the first endovascular stent graft to treat an AAA on 7th September, 1970, started the endovascular revolution, ensuring that vascular surgeons today are not an extinct or endangered species. The patient had a AAA, back pain, and severe chronic obstructive pulmonary disease. He survived 9 years and succumbed to pancreatic cancer.[11]

A majority of patients requiring arterial intervention often have multiple co-morbidities. Hence, EVT, most of which can be performed under local or regional anesthesia is preferred. Endovascular hardware and software have improved significantly since 1970, bringing about changes in guidelines internationally that suggest EVT as the first option for both arterial and venous disorders. Technology has today reduced the number of open surgical interventions.

Patients and referring doctors are well informed about EVT thanks to the Internet and continuing medical education (CME), being aware of the decreased hospital stay, although at a cost.


  Challenges in Offering Endovascular Therapy Top


Endovascular hard/software is expensive, not uniformly available across the country and requires the end-user to be trained to get optimal results. Setting up a Cath lab can cost between 3 and 10 crore INR.[12]

Majority of the Indian population is uninsured and has to bear the cost of treatment “out of pocket.” These numbers are 67.8% in rural households and 74.9% in urban. The government supported schemes insure about 13% of the rural and urban population, as against 1% and 6%, respectively being covered by an employer or self-sponsored health insurance.[13] It is this lack of funding that deprives patients of the benefits of EVT.

EVT requires re-intervention in challenging cases and acceptance of this by the patient/family and insurance agencies is poor. The reader must bear in mind that these patients would be those at high risk for open surgical (re-anaesthesia) intervention.[14]

A third challenge is to have centers with personnel trained in offering EVT across the country. Those that offer EVT should have a standard operating procedure (SOP) and be encouraged to maintain a registry that would help audit their success rates.

As health professionals, patients not coming for follow-up and “window shopping” at centers make auditing of outcomes difficult.


  Potential Solutions to the Challenges Top


It is the duty of a mentor to equip a mentee with skills that are in keeping with the “times.” This would require for the mentor to be trained and dare I say be coached so that they and the trainees are not an endangered or extinct species.[15] Information about EVT options can be transferred to health professionals through CME's, conferences, workshops, and online resources. Patients can then be followed up locally after their treatment and feedback given to the primary team. It is encouraging to see an active role being played in this regard by several institutes/hospitals in the country, the Vascular Society of India, and the Venous Association of India.

The Madras Medical College, Chennai, set up an endo-suite and was the first for a government hospital in the country, to be used exclusively by the vascular surgery department.[10] This was made possible by the donation of a used C-arm machine. Institutes/hospitals should look at this option so that the initial cost of installation of a Cath lab can be curtailed and training provided.

One-way to reduce the burden of cost to the patient is by “secondary/re-use” of disposable equipment. This is a way to offer current medical therapy to those who deserve EVT and find it difficult to pay full or part of the cost of treatment.

India has been criticized for its secondary/re-use of disposable equipment. International good clinical practice guidelines need revision to include the real-time situation is low- and middle-income countries and I hope will include guidelines on the above matter.[16] Health-care organizations would argue that reuse makes for a “greener” environment with a decrease in medical waste. It appears that the reuse of single-use equipment has produced near-identical results and no patient harm if it is properly reprocessed.[17] SOPs for this should be in place and will curtail cost to the patient/institution/government.

The Indian government introduced cost regulation on cardiac stents and the same could be done for the entire gamut of currently existent EVT equipment and those that would be brought into the market.

Patient information handout in the local language should be made available while discussing treatment options so that an informed decision is made stressing on the need for follow-up and the likelihood of re-intervention, when necessary. It should contain details that include a helpline number and e-mail address that is responded to regularly.


  Conclusion Top


EVT is here to stay. It is the duty of health professionals involved in offering this modality to work alongside the government with support from colleagues and their professional societies and ensure that most, if not all, get the benefit of the endovascular revolution.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Available from: http://www.indiamart.com>VascularConceptsLtd' Products & Services. [Last accessed on 2020 Mar 19].  Back to cited text no. 1
    
2.
Available from: http://mdiabetes.nhp.gov.in. [Last accessed on 2020 Mar 19].  Back to cited text no. 2
    
3.
Ahirwar R, Mondal PR. Prevelance of obesity in India: A systematic review. Diabetes Metabolic Syndrome Clin Res Rev 2019;13:318-21.  Back to cited text no. 3
    
4.
Unnikrishnan M, Savlania A, Goura P, Verma H, Tripathi RK. An experience from two large centers in South India. Indian J Vasc Endovasc Surg 2016;3:20-3.  Back to cited text no. 4
  [Full text]  
5.
Available from: http://www.businesswire.com>news>home>SAGE-GROUP-Peripheralarterialdisease. [Last accessed on 2020 Mar 19].  Back to cited text no. 5
    
6.
Krishna M, Oommen AM, Paul JS, George AK. Prevalence of intermittent claudication in rural and urban Vellore, Tamil Nadu, India: A population – based study. Int Surg J 2018;5:2620-2.  Back to cited text no. 6
    
7.
Available from: http://timesofindia.indiatimes.com>Etimes>Life& Style>Health&Fitness. [Last accessed on 2020 Mar 15].  Back to cited text no. 7
    
8.
Selvaraj D, Kota A, Premkumar P, Stephen E, Agarwal S. Socio-demography and clinical profile of venous ulcers. Wound Med 2017;19:1-4.  Back to cited text no. 8
    
9.
Selvaraj D, Premkumar P, Raj SP, Kota A, Agarwal S. Socio-demography and clinical profile of venous ulcers, Wound Med 2014;5:1-3.  Back to cited text no. 9
    
10.
Vidyasagaran T. President's address- VSICON 2017. Indian J Vasc Endovasc Surg 2018;5:9-11.  Back to cited text no. 10
  [Full text]  
11.
Endovascular Revolution in the Aorta: 25 Years of a Landmark Case; 26 January, 2016. Available from: http://vascularnews.com. [Last accessed on 2020 Mar 19].  Back to cited text no. 11
    
12.
Medical Consultants & Clinics. Available from: http://www.indiamart.com. [Last accessed on 2020 Mar 20].  Back to cited text no. 12
    
13.
Baxi M. Meeting India's Healthcare Needs. Available from: https://indusdictum.com/2018/03/06/meeting-indias-healthcare-needs-national-health-protection-scheme-mihir-baxi/. [Last accessed on 2020 Mar 20].  Back to cited text no. 13
    
14.
Saraidaridis JT, Ergul EA, Clouse WD, Patel VI, Cambria RP, Conrad MF. The natural history and outcomes of endovascular therapy for claudication. Ann Vasc Surg 2017;44:34-40.  Back to cited text no. 14
    
15.
Stephen E. Paradigm shift in mentoring. Indian J Vasc Endovasc Surg 2019;6:63-4.  Back to cited text no. 15
  [Full text]  
16.
Ravinetto R, Tinto H, Diro E, Okebe J, Mahendradhata Y, Rijal S, et al. It is time to revise the international Good Clinical Practise guidelines: Recommendations from non-commercial North-South collaborative trials. BMJ Glob Health 2016;1:e000122. Available from: http://dx.doi.org/10.1136/bmjgh-2016-000122. [Last accessed on 2020 Mar 20].  Back to cited text no. 16
    
17.
Mansur JM. Reuse of Single-use Devices: Understanding Risks and Strategies for Decision-Making for Health Care Organizations. Available from: http://www.jointcommissioninternational.org. [Last accessed on 2020 Mar 19].  Back to cited text no. 17
    



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[Pubmed] | [DOI]



 

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Abstract
Introduction
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