Endovascular Aortic Repair (EVAR) in the Case Hospital

國

立 政 治 大 學

‧

N a tio na

l C h engchi U ni ve rs it y

52

suffering, saving lives, and to sow the seeds of love in every community and around the world.‖

4.3 Endovascular Aortic Repair (EVAR) in the Case Hospital

4.3.1 Introduction of EVAR into the Department of Cardiovascular Surgery The innovation strategy of our hospital is not only to establish various medical specialties, exceptional fundamental, and state-of-the-art clinical services, but also to develop micro-invasive operations to minimize patients‘ suffering. The department of cardiovascular surgery, following this strategy, has been providing both conventional major cardiac and vascular surgery and minimally invasive cardiac surgery including off-pump coronary artery bypass grafting (OPCAB), videoscopically-assisted cardiac operations (eg. EndoACAB, videoscopic mitral valve repair, and etc), and traditional cardiac operations though small wounds. Every effort had been exercised to make the organization an efficient and safe one. This is our regular innovation strategy.

As afore-mentioned in the first section of this chapter, for a 750-bedded regional hospital with sufficient resources and supporting system and located in the metropolitan area full of competition, we must consider periodic revolutionary innovation on top of continuous regular innovation to keep the hospital from stagnation. Though the two senior cardiovascular surgeons, amongst whom the author is one, were trained in the traditional ways in their residency and have been practicing accordingly for a long time, we agreed to this point of view and decided to embrace the chance to adopt a revolutionary surgical technique, that is EVAR, early in 2009.

We simultaneously started our thoracic endovascular repair (TEVAR) program. While TEVAR shared many similar technical requirements with EVAR, it is not included in the study.

At the same period of time, in our daily practice, we treated patients with

‧

立 政 治 大 學

‧

N a tio na

l C h engchi U ni ve rs it y

53

abdominal aortic aneurysm larger than 5.0cm routinely with transperitoneal open abdominal aortic aneurysm resection and grafting, which had been the traditional and well-established treatment modality. As part of the innovation program, we had to prepare the whole surgical team for the necessary knowledge and surgical techniques through off-line lectures and on-line practice. The two surgeons attended several simulation courses and had been practicing peripheral vascular interventions to train themselves with the catheter techniques mandatory to the new procedure. An experienced endovascular surgeon was invited to supervise the first five cases.

Not only EVAR in comparison to the traditional open surgical repair (OSR) is an innovatively new procedure, but also the devices (endovascular stentgraft) to be implanted are much more complex and expensive than the vascular prosthesis used in the traditional open surgery. To cope with these challenges, a new business model between the industry and the medical service providers (including the case hospital) in Taiwan has been developed.

4.3.2 Conduct of EVAR in Regional Hospitals (including the case hospital) in Taiwan

For several decades, cardiac and vascular surgeons are trained and required to be familiar with both their surgical techniques and the characteristics of those medical devices to be implanted. In the hospital settings, a whole range of prosthesis or devices of different models and sizes should always be available on shelf for elective and emergent operations. During an operation, a surgeon can modify his/her surgical procedures upon observation of the particular anatomical variation and the actual model and size of the prosthesis most of the time is determined after assessment of the patient‘s anatomy during the operation.

In the daily practice of the open surgical repair, a patient sees a doctor for

‧

立 政 治 大 學

‧

N a tio na

l C h engchi U ni ve rs it y

54

surgical consultation and performance of the operation. The surgeon provides recommendation on choices of treatment and conducts the operation with his surgical team in the operation theater. After the operation, the surgeon also takes care of the patient in the ward and later in the out-patient department. Patients generally don‘t need to have further computed tomography angiography after open surgical repair unless specifically indicated in certain circumstances. The fee for medical services and expenditure on prosthesis are reimbursed separately by the insurance company (in Taiwan‘s case, the national health insurance system). The business model of the traditional surgery melieu is demonstrated in Fig. 4.2.

Figure 4.2 Business model of the traditional surgery melieu. (source: the study)

The service process of EVAR is slightly different from OSR. Before each operation, surgeons have to read the reconstructed computed tomography angiography (CTA) to make a surgical planning, comprising steps of procedures and the proposed choices of model, size and length of the endovascular stentgraft to be implanted.

During the operation, the whole procedure is conducted under real-time fluoroscopy and angiography guidance. Postoperatively, patients are followed up closely on

‧

立 政 治 大 學

‧

N a tio na

l C h engchi U ni ve rs it y

55

out-patient basis and must undergo periodic computed tomography angiographies according to the institute policy and protocol. During each operation, the steps of procedures can vary because of anatomical and technical consideration and the actual model, size and length of the endovascular stentgraft to be implanted can also vary a lot. Traditionally the vascular prostheses are supplied on the shelf. This can be a problem for endovascular surgery considering the complexity and high price of the devices.

To conquer this situation, the industry and the medical service providers have developed a new business model. The industry has now a ―technical sales specialist‖

who is well trained in the knowledge of endovascular surgery and very much familiar with its devices. While surgeons are performing the operation, the technical sales specialist will be in the operation room carrying ample supply of a wide range of models and sizes of the endovascular stentgraft and to offer detailed information on those devices to the operating surgeons. Instead of a sales specialist, he/she also serves as a technical specialist when it comes to the special features of the devices.

The business model of the EVAR melieu is demonstrated in Fig. 4.3. Details of the development and operation of the business model will be prescribed further in the section of analysis of the in-depth interview.

‧

立 政 治 大 學

‧

N a tio na

l C h engchi U ni ve rs it y

56

Figure 4.3 Business model of the EVAR melieu. (source: the study)