Pushing the Limits of Hybrid Vascular Procedures

Complex vascular disease rarely follows a standard treatment strategy.

For patients with challenging anatomy, limited vascular access, significant comorbidities or complex aortic disease, traditional approaches may not be enough. Hybrid vascular procedures combine open surgery with minimally invasive endovascular techniques to expand treatment options and deliver more individualized care.

In this Baptist Health Doc-to-Doc discussion, Dr. Tom Nguyen is joined by vascular and endovascular surgeons Dr. Young Lee and Dr. Ignacio Rua to examine how hybrid approaches are changing clinical decision-making for complex vascular disease and helping physicians treat patients who previously had limited options.

Topics include:
• Open, endovascular and hybrid treatment options: How to choose the right approach
• Physiologic age vs. chronological age in treatment planning
• Multidisciplinary planning for complex aortic disease
• Advanced imaging, 3D reconstruction, image fusion and intravascular ultrasound (IVUS)
• Reducing contrast and radiation exposure in patients with renal disease
• Training the next generation of vascular specialists
• Robotics, artificial intelligence and emerging vascular technologies
• Research in venous valve replacement and limb preservation
• When early referral and second opinions create new treatment options

Learn more about Baptist Health Heart & Vascular Care and its comprehensive vascular services at BaptistHealth.net.

Experts:
Tom C. Nguyen, M.D. 
System Chief Executive, Baptist Health Heart & Vascular Care 
Chair and Professor, Cardiovascular Sciences, FIU

Young Lee, M.D. 
Vascular & Endovascular Surgeon 
Baptist Health Heart & Vascular Care

Ignacio Rua, M.D.
Vascular & Endovascular Surgeon
Baptist Health Heart & Vascular Care

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Transcript

SPEAKER_02 0:00

Today, we're exploring hybrid vascular 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.

SPEAKER_01 0:34

Welcome to Baptist Health Doctor Doc, a podcast built for innovation and collaboration by physicians for physicians.

SPEAKER_02 0:42

Hello, I'm Dr. 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. Young Lee, Vassular and Endovascular surgeon with Baptist Health, Heart and Vascular Care, and Dr. Ignacio Rua, Vascular and Endovascular Surgeon, also with Baptist Health, Heart and Vascular Care. Good morning. Thanks for joining us to say. Thank you.

SPEAKER_00 1:09

Thank you for having us.

SPEAKER_02 1:10

For physicians who may not perform these procedures every day, how do you define hybrid vascular procedures and why has it become such an important treatment option for our patients?

SPEAKER_00 1:21

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.

SPEAKER_02 2:17

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?

SPEAKER_00 2:24

Layman terms, we go in through the arteries or veins using wires and catheters and either open up occlusions or place stent graphs to exclude aneurysms and um and carotid disease. We put in stents.

SPEAKER_02 2:41

Dr. Ro, 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 has endovascular treatments really evolved in our patient management managing management process?

SPEAKER_03 2:55

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 uh uh wonderful to see this whole uh transformation. And now we're moving on into uh another transformation where you have uh op incredible open techniques now super evolved and uh super uh uh you know incredible technologies, endovascular, and now we're witnessing uh 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 abode without having to open these major body cavities.

SPEAKER_02 4:05

Dr. Lee, when these patients come to see you all, how do you decide whether patient gets a hybrid or an open surgical approach?

SPEAKER_00 4:12

So I look at the patient as the whole. Age is not my only limitation because there is 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's 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, but don't have the appropriate access. For example, their iliac arteries or their common february 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.

SPEAKER_03 5:32

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's true, it's not the 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.

SPEAKER_02 6:13

Uh you bring up a really important point. I think in medicine, we look a lot about the biological age, not the chronologic age. And in the past, a 70, 80, 90-year-old, we definitely would not touch at all. But now, especially with advances in endovascular techniques and even some open techniques, uh, not uncommonly, you all uh and and us are are intervening in patients uh in their 90s and sometimes uh centenarians as well. Yeah. Can you tell me, do all vascular surgeons do open and hybrid? And do all most vascular programs do a combination of open and hybrid?

SPEAKER_03 6:49

No, definitely not. There's uh you know, there's uh you know, it's a 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 aneur aneurysmal disease is now man 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 to those skills have to be passed on. And so it's it's important that a program be able to do uh anything open, anything endovascular, and now in these same programs do them in a hybrid uh manner.

SPEAKER_02 7:48

That's you're 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 importance of collaboration and multi-specialty involvement with with maybe the decision-making process and maybe even with the procedure itself.

SPEAKER_00 8:11

So I'll take aorta for an example, because we have a significant aortic volume here at my 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.

SPEAKER_03 9:44

We we have a um aortic conference every Wednesday. In fact, just just this uh just yesterday had an amazing conference. We had 37 multidisciplinary physicians. Uh I mean, we're talking from car cardiothoracic, vascular surgery, interventional radiology, anesthesia, vascular medicine. Vascular medicine and 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 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.

SPEAKER_02 10:28

You both hint hinted at this a little bit, but if you can elaborate a little bit more, what makes a program at Baptist Health, Heart and Vastor a little bit different than than other programs out there?

SPEAKER_03 10:37

I I would tell you, it it has to be the the level of collaboration. There's no I you know, there's no real turf battles. Everything is is uh resolved, everybody's very collegial and uh 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. Whereas 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.

SPEAKER_02 11:18

Uh Did Lee, anything to add to that?

SPEAKER_00 11:21

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.

SPEAKER_03 11:49

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.

SPEAKER_02 11:57

Well, we have partnerships with other hospitals, and not uncommonly, you all are going to our neighboring hospitals, Nicholas, to help younger patients with aortic and vascular pathology as well. And I'll also add that I've been involved in a lot of 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 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 are we missing uh for the treatment of uh endovascular uh peripheral vascular disease?

SPEAKER_03 12:56

Well, I can I can start, you know, uh I remember, you know, let's say a CT scan in the early 90s. You know, the really large cuts. And uh, you know, you'd get uh, I don't know, half a centimeter, even a 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. I mean, you you go into, let's say, a a carotid lesion, you know what the plaque's gonna look like. You is it gonna be soft? Is it gonna be hard as a rock? Is it gonna be ulcerated? And it's it's just uh and it's incredible, incredible technology. So I I personally just fascinated with CT, but you can tell us we have a multitude of other technologies as well.

SPEAKER_00 13:44

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 Mammy 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.

SPEAKER_02 15:16

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 radiology. What's what's that looking like here at Baptist?

SPEAKER_03 15:32

It's very another very exciting time period. I mean, now we have an incredible relationship with FIU. We have uh, you know, medical students rotating on our service. We you know 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 uh to partake in that.

SPEAKER_02 16:09

And Dr. 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?

SPEAKER_00 16:17

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, we'll 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 diversity in people's backgrounds just bring better options for the patients all around.

unknown 17:02

Definitely.

SPEAKER_02 17:03

We're talking a lot about the present with the present technologies available and current training. But what does a future look like for treatment of aortic pathologies, peripheral vascular disease, um, whether it be technologies or structure of programs, or what do you what would you imagine?

SPEAKER_03 17:20

Young and I were just talking about this yesterday. The uh the there's now another revolution in robotics. You know, there's a new generation uh uh robotic uh companies that uh I know Baptist is uh participating in. And in at least in the the vascular uh sphere, we're just scratching the surface. We're both of us say we definitely want to 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 uh a really uh incredible uh push and fe uh in this field.

SPEAKER_00 17:59

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 kinds 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 just 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.

SPEAKER_02 19:01

As you 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?

SPEAKER_03 19:23

Uh one of our partners, uh again, we were just discussing this yesterday. One of our partners, Dr. Michelle Talman, uh is fearheading an effort in uh replacing the deep uh uh valves. Venus 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 uh percutaneous valves replacement, and Baptist is going to participate in that and uh uh in that uh research, which is you know the entire country.

SPEAKER_00 20:03

We have another project going on that we're working with Florida International University and the Bioengineering and Pathology Department there 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.

SPEAKER_02 20:33

Lastly, if uh there's a community physician out there that wants to refer a patient to you, Mall, uh what's the best way of referring a patient to the institute?

SPEAKER_03 20:44

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 uh better treatment options. The earlier we we get involved with the patients.

SPEAKER_00 21:05

I would also like to encourage that Do you know the telephone number?

SPEAKER_03 21:09

No, not that's okay.

SPEAKER_00 21:11

We can show the number later. 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 it's the end for that patient. If somebody else does not offer an option, it is always worth a second opinion. And referring to us, because again, as a mega institution and a coordinary 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 okay. Refer it to us and we'll take a second look.

SPEAKER_02 22:04

I think that's so important because a lot of times people think uh 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 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?

SPEAKER_00 22:34

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.

SPEAKER_03 23:03

So Yeah, no, it's just again, this is a very exciting time to be in vascular surgery at uh uh BAPTIS because Baptist is now embarking on uh more and more hybrid rooms. This and you know, stepping into an operating room today is just incredible.

SPEAKER_02 23:21

It's a very exciting 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, Dr. Lee and Dr. Will, 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 community. Thank you. Thank you.

SPEAKER_00 24:16

Thank you very much.

SPEAKER_01 24:17

To find out more about the topics covered on Baptist Health Doctor Doc, please visit physicianresources.baptisthealth.net.