Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we have a panel exploring open and endovascular options for aortic surgery and how surgeons approach treatment when standard endovascular access or repair is not possible. Our discussion highlights how careful understanding of anatomy, surgical planning, and long-term follow-up can help guide treatment decisions for patients with complex aortic disease.

Joining me in this panel is Dr. Martin Back. He's a Professor of Surgery and Chief of the Division of Vascular Surgery and Endovascular Therapy at the University of Florida College of Medicine. And Dr. Eric Jeng, he's the Director of the UF Health Aortic Disease Center and an Associate Professor in the Division of Cardiovascular Surgery at the University of Florida College of Medicine.

Doctors, thank you so much for joining us today. And Dr. Back, I'd like to start with you. Can you describe a little bit about the current state of aortic surgery? Help us to understand the historical context and current trends in open surgical repair versus endovascular approaches for the treatment of aortic disease.

Dr. Martin R. Back: Thanks, Melanie. It's come a long way. You know, currently, endovascular approaches to a lot of aortic pathologies really dominate the field and what's practiced across the country and even around the world. It was 1999 the FDA approval of the first devices for treating infrarenal aortic aneurysms in this country that it kind of opened the door to the endovascular revolution as it was.

The complexity of endovascular treatments to now treat kind of branch segments of the aorta, such as across the visceral aorta and across the aortic arch have continued to evolve with the technology. And I think that the endovascular approaches have replaced some of the aortic open operations in many cases, but certainly don't completely replace it. There are needs for open operations that are still performed at all levels of the aorta, and Eric can talk more to some of the thoracic aorta and ascending and arch areas below the diaphragm. There are still open operations that are required for complex anatomies that can't be handled with endovascular therapy. So, open and endovascular approaches I would consider complementary in treating various pathologies. And sometimes in patients, the complexities require hybrid approaches or some combination of endovascular and open approaches.

Melanie Cole, MS: Well then, Dr. Jeng, please speak about some of the indications. Let's start with the advantages and limitations of open surgical repair, and then we're going to move on to the endovascular approaches, and we'll compare and contrast those.

Dr. Eric Jeng: Thank you, Melanie. I think the open approaches obviously give you a one-stop shop to that pathology, wherever that pathology may be in the ascending aorta, the ascending arch, or even the proximal descending aorta or even the complete thoracoabdominal aorta. That being said, the open approaches frequently have an increased morbidity and at least short-term mortality.

The benefit becomes in the short term for the endovascular procedures. But long term, I think you have to have more surveillance in the endovascular procedures as opposed to the open procedures.

Dr. Martin R. Back: I'd like to add, we know with treating thoracoabdominal aneurysms and aneurysms and other pathologies below the diaphragm as well, secondary interventions after initial endovascular repairs probably, you know, are required in at least one in five or 20% of patients. And so, surveillance for the patient's remaining lifetime is needed with repeated CT scans in general for that surveillance.

The equivalent outcomes have been achieved in the abdominal aorta, for example, between endovascular and open. If the mission of the operation or the procedure is to keep the patient from dying from their aneurysm treatment or keep the aneurysm from rupturing, both of these approaches have been able to accomplish the same mission equally, but with their pros and cons of less morbidity up front with an endovascular approach, a little more morbidity with the open approaches and the need for secondary interventions later with the endovascular thing. So, again, you know, complementary approaches that can be tailored to patients' anatomies both achieving same kind of outcomes which is keeping aneurysms from rupturing, for example.

Dr. Eric Jeng: To add to that, Melanie, I think there are parallels even in the cardiovascular surgery or in cardiovascular medicine world. Frequently, patients get stents because they don't want open heart surgery as opposed to coronary bypass operations. And we know long-term in specific disease pathologies, yeah, stents may work in the short term, but at the end of the day, you get more interventions, repeated interventions, when compared to open coronary bypass operations.

You'll see that there are certain subsets where the gold standard is open surgery, but depending on what the patients prefer and what their disease pathology and what they look like at that moment in time clinically, that may favor one type of operation over another. Meaning if they're more healthy, maybe they could withstand an open surgery; versus less healthy, an endovascular approach may be the better of the options.

Dr. Martin R. Back: And finally, Melanie, you did ask me about, you know, the historical perspectives. I gave you a little bit of kind of the original dates of some of the endovascular interventions. In a thoracic aorta, first FDA-approved devices were in 2007.

That being said, endovascular approaches were initially proposed to be able to handle the higher medical risk patient. And so, you were going to be doing endovascular things in sicker people that had higher risks of complications and death from an open operation.

Well, that's come and now spread into kind of all risk categories. You know, you give patients a choice, and they want something that's less morbid upfront and a quicker recovery, and something done through smaller incisions and transfemoral approaches to get an endovascular approach compared to a big open operation, longer hospitalization, bigger recovery, and return to functionality for the patients.

Dr. Eric Jeng: But this is exactly why an aortic center or multidisciplinary approach is the key concept here, because you get thought leaders in every category. And like we've talked about before, you get less siloing of information. And for the patients themselves, they get a comprehensive approach and a multidisciplinary approach to get the best solution and a customized solution for their customized state of being.

Dr. Martin R. Back: And, you know, we meet regularly. The other thing is what Eric and his colleagues do and I and my colleagues do, we overlap quite a bit in the patients that we take care of. And so, it's good to get a consensus from our group. We meet at least twice a month, review many cases with complex aortic anatomies, aneurysms, dissections and the like and, as a group, decide what are the best approaches for some of these patients and recommend that and then perform them. We do a lot of combined procedures together. So in this type of a center of excellence, you're getting the best of his talents and my talents, you know, in treating a given patient. I mean, that gives the patient the best chance of getting through and getting their pathology treated safely.

Melanie Cole, MS: Well, that's certainly a comprehensive approach with the importance of that multidisciplinary aspect. So, Dr. Jeng, when we think of the key anatomic and clinical factors, and you mentioned shared decision-making and what the patient really wants. And I'm sure that that is a little bit challenging for patients to think of that open repair and open heart surgery.

Tell us a little bit about your management strategies for aortic anatomy when maybe that presents the challenge to your standard endovascular access or repair techniques, whatever their clinical factors might be. How are you working with them, and then how do you help them to make those decisions based on your expertise?

Dr. Eric Jeng: Because we work so closely with, I mean, even the interventional cardiologists, the radiologists, the vascular surgeons, we come up with what we think is the best and the simplest approach, and sometimes that's open surgery. We offer the patients all of these decision-making pathways, and they end up having the free will to decide which direction they want to go.

That's where the informed consent comes into play, where we explain all the risks, all the benefits, the short-term morbidity, the short-term mortality, the long-term benefits, and that's how we end up deciding one thing or another. We're not peg-holed into deciding either open surgery or endovascular surgery because myself and Dr. Back, we both perform endovascular and open operations, and very complex ones. And so, we offer the patient what they need with the least morbidity and mortality that we can.

Dr. Martin R. Back: And that being said, you know, Eric, we know that the endovascular versus open interventions differ based upon pathologies at various locations, but also by location in the aorta.

So for example, in the ascending aorta, we have very few options endovascularly at all. They're really more considered experimental currently through some trials. It's mostly open repairs of the ascending aorta. The arch is now evolving to maybe more complex endovascular options, although it certainly has not supplanted or replaced the need for open surgeries.

Down the rest of the thoracic aorta, there's a lot of endovascular repairs that are now possible for pathologies and dissections and, aneurysms that are probably maybe better and safer and get those equivalent outcomes to the open operations. When you come across the branches that go to the intestinal arteries and the renal arteries, the endovascular repairs are much more complex. And there are patients that have anatomy that doesn't lend itself to even a complex endovascular repair, still requiring an open operation. And you get down to the abdominal aorta below the kidney arteries, down into the iliac arteries, certainly endovascular interventions have replaced many of the open operations although open operations can certainly be done.

So, you know, we tailor our recommendations based upon what the anatomy is, what the pathology is, and what locations of the aorta there are. And then, relative to the patient's preoperative risk, their relative frailty, what we anticipate with their potential recovery and their complication rates, relative to underlying disease processes that, you know, can be cardiac, pulmonary, renal, or other in nature. So, there's a whole bunch of factors that go into these kind of equations to make the best decisions for an individual patient.

Dr. Eric Jeng: I think Dr. Back started with this initially. At the end of the day, an open operation will always be necessary for something that endovascularly fails. So, you need experts in the field like Dr. Back and myself to be able to come in and replace an aorta open when necessary, because sometimes these same stents they cause issues. And there's nothing you can do to recover them. And so, an open operation is the last stop at the end of the day to be able to save the patient.

And that's really what it's all about, and it's always been what it's about: the patients and being able to offer them the best option. And open surgery happens to come into play when there's infections related to the aorta or, for some reason, the endovascular options fail. And so, open surgery, again, is sometimes the last resort. But you need to have that expertise in your center when you're helping patients, and it can't just be one or the other.

Dr. Martin R. Back: There is an evolving problem in the country. The number of open repairs of aortic pathology, especially aneurysms, is falling because there's such predominant use of the endovascular techniques.

And with that happening, there's fewer and fewer places that have familiarity and the technical abilities to perform open aortic operations. So, it's falling upon tertiary centers regionalized referral patterns and centers of excellence where there are surgeons who can still perform open operations.

That is a lot of our business here is referred from at least a three-state area here in the southeast United States for complex scenarios that are going to require an open operation that other folks out in the community are just uncomfortable with.

Dr. Eric Jeng: And I may have said this before, but at least last probably five to 10 years, we historically have been the second leading aortic center in the country by surgical aortic volume, most recently performing about 1,000 aortic cases split between cardiac surgery and vascular surgery every year. So, we are a high-volume center and high complexity center, and we're open to helping people with less complex business also. So, anybody that wants to send any of their patients that are less complex, we're open to that too.

Melanie Cole, MS: Dr. Back, I'd like you to expand for a second because we've done a previous podcast about trainees and residents, and you mentioned the lack of ability to do open with all the technology for endovascular. Can you identify some of the barriers to that robust open surgical training exposure? When you think about the technology that's available today, whether it's robotics or imaging techniques, there's so many different things going on in your field which makes it so exciting, what would you like other providers to know, as Dr. Jeng was saying about the high volume that you're doing, that in emergent situations, the surgeon needs to be able to switch in a minute's notice. Tell us a little bit about how that works in your aortic center of excellence.

Dr. Martin R. Back: So, we have an active fellowship. Fellows are in vascular surgery have already had five to six years at least of general surgical training and then join a fellowship. We are one of about 75 programs across the country that have fellowships. There are other vascular surgery residency programs about equivalent numbers.

And frankly, you know, across most of the country, the finishing residents or fellows have fairly low numbers of open aortic experiences. And so, they may not have had enough experience to really feel comfortable going out and practice and offering that, treatment. And that has been a growing problem in the country.

Now, our fellows finish with gigantic numbers of open aortic exposures, and I think we're training some of the best fellows to go out and try to maintain that populace of really highly skilled vascular surgeons able to perform aortic nterventions, both endovascular and open.

So, we can only fix our shop. And we can't fix the shop of others, but it is a growing problem. I'm not sure there's really currently similar problems in cardiothoracic surgery, and I'll let Eric talk about that. But it is a problem in vascular surgery. Will there be a surgeon for me in 25 years when I form an aortic aneurysm and I need it fixed open? Is there anybody around who's going to be able to fix it safely?

Melanie Cole, MS: I would love to give you each a chance for a final thought, because this is such an interesting discussion. We could go on a long time, because there are so many avenues to the complex work that you both are doing. And so, Dr. Jeng, what would you envision as the future of aortic surgery in your ideal world? Are there emerging trends, innovations that you feel will shape the future of complex aortic surgery? What would you like to see happening and what's coming down the pipeline?

Dr. Eric Jeng: As I may have mentioned before, I am the program director for the integrated residency program also. And what we do is we integrate simulation as well as because of our patient population status, we have a lot of open aortic surgeries, and we train people on simulation runs as well as in real life on patients. They operate on patients. They contribute directly to the care of these patients.

And so, in our center, because we do so much aortic surgery, our residents are very comfortable operating on aortas. And in fact, most of the nation, a cardiac surgeon mainly does coronary bypasses. All of our residents blow out the numbers from a standpoint of aortic cases that they log.

So, because we're strategically located a place with so many experts in the different fields like vascular radiology, cardiac surgery, cardiac anesthesiology, all these silos come together. And so, because of that, we're exposing our residents to both the open and the endovascular approaches, and they see when things work and when things fail. And so, they'll know in the future how to tailor their practices and how to manage their patients. And that's really the goal of our program, not only to help our community, but to help train our residents and the future doctors so they can help the communities in the future. And in a program like this, we have both the open and the endovascular and the robotic technologies to be able to train the surgeon of the future.

Melanie Cole, MS: Such an important point. And Dr. Back, last word to you. What would you like other providers to take away from this multidisciplinary information about the Aortic Disease Center at UF Health? And what would you like them to know about working with patients in that shared decision-making on open versus endovascular aortic disease when you're thinking about that surgical planning?

Dr. Martin R. Back: So, a couple final points. I think the last area of really challenge is the ascending aorta in terms of endovascular approaches. It's highest flow greatest dynamic movement of the wall and the aortic valve. And so, there are a lot of challenges. And so, we are part of some clinical trials for new devices in the ascending aorta, and I think it's kind of the last area of, really, endovascular challenge, although there's certainly complex anatomies throughout the aorta. The ascending aorta is one of those.

And, you know, finally, I'd like to make a pitch for our aortic symposium. I think what we've tried to create in the last three years and now going on our fourth year is a unique program that highlights how cardiac surgeons and vascular surgeons can interact, treat complex aortic pathologies, and how to perform some of these complex procedures. This year, we're going to focus primarily on kind of how-to videos of, techniques for treating the aorta in various locations, both endovascular and open. And I think this is a unique format that we've had running four years now in that there are lots of endovascular symposiums across the country that are done in the vascular world, and it's all endo, endo, endo. But this is unique that it's bringing together some combined surgical and endovascular approaches, multidisciplinary decision-making, and procedural performance. I think there's a lot that can be taught and learned by folks that attend this meeting. So, I'm making a pitch for attendance at this if you can help spread the word for us.

Dr. Eric Jeng: December 2026 in Orlando.

Melanie Cole, MS: There you go. I was going to ask you when the date was, so thank you for sharing that. And thank you both for coming on. It really is such an exciting time in your field. This was a fascinating discussion, thought leader roundtable. So interesting. Thank you both for joining us and sharing your incredible expertise for other providers.

To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole.