Endovascular Therapy – Minimally Invasive, Interventional Treatment Options for Arterial Vascular Diseases

Endovascular (endo = inside, vascular = relating to blood vessels) therapy is a term used to describe all procedures in which diseased blood vessels are treated from the inside. For example, in cases of circulatory disorders (such as peripheral artery disease), narrowed or blocked arteries can be dilated or restored to patency.

Conversely, in cases of bleeding, damaged blood vessels are sealed or stented from the inside, thereby stopping the bleeding.

The greatest advantage is certainly that the vessels to be treated do not need to be exposed along their entire length via large skin incisions. Instead, the treatment is performed through a small access point, usually in the groin.

From there, balloons, catheters, and stents are advanced into the affected vessel under X-ray guidance. All of the body’s blood vessels can be treated via the groin access, including, for example, cerebral arteries or the coronary arteries. 

Endovascular therapy uses devices such as balloons and stents to ensure healthy blood flow @ Axel Kock /AdobeStock

The femoral artery is accessed externally through the skin; due to its superficial and easily accessible location, it is the preferred access vessel for endovascular therapy. The procedure can therefore usually be performed under local anesthesia and places minimal strain on the circulatory system.

This is another advantage of endovascular procedures, particularly for older patients with pre-existing conditions and an increased risk associated with general anesthesia.

Common indications for endovascular procedures include:

• Intermittent claudication (peripheral arterial disease)

In this condition, narrowings or blockages in the leg arteries can be dilated and widened using balloons or stents. This restores blood flow to the lower leg and foot.

• Aortic aneurysms

Abnormal dilations of the aorta are treated from the inside using metal mesh covered with plastic (stent grafts), which can prevent death from hemorrhage if the vessel wall ruptures.

• Aneurysms of the leg arteries (popliteal aneurysm)

Aneurysms of the popliteal artery are also a common indication for endovascular treatment. In this procedure, a stent prosthesis is advanced into the dilated popliteal artery, thereby treating it from the inside as well.

The goal here is to prevent clots from breaking off the dilated wall and traveling down into the lower leg or foot, where they could cause critical circulatory disorders.

• Heart Attack

A heart attack involves a sudden blockage of the coronary arteries, leading to severe blood flow impairment in the heart muscle and resulting in severe pain behind the breastbone. In most cases of acute heart attack, the coronary arteries are dilated and treated with stents.

This is performed by internists (cardiologists). If this is not possible, a surgeon (cardiac surgeon) must expose the heart and its vessels as quickly as possible via a large incision in the chest and create one or more bypasses. However, the risk of death during surgery is very high, which is why endovascular therapy is generally preferred.

• Stroke

A stroke is caused by an acute disruption of blood flow to parts of the brain. Depending on which part of the brain is affected, different symptoms may occur.

A stroke often manifests as paralysis on one side of the body, affecting the arms and/or legs; in addition, loss of consciousness, speech difficulties, or visual disturbances usually occur.

The causes include either narrowing of the carotid arteries, which can be widened and treated with a stent using endovascular procedures. Another common cause is clots that have traveled to the brain, often forming in the heart due to cardiac arrhythmias.

These clots can be dissolved with specialized medications, thereby restoring blood flow to the downstream brain tissue.

Depending on the severity and duration of the blood flow disruption, the tissue may recover partially or completely, so that, ideally, there are no lingering effects of the stroke.

• Varicose Veins

Varicose veins can also be treated using endovascular procedures. However, in the case of varicose veins, the term “endoluminal therapy” is most commonly used, since these are vessels of the venous system (veins). In contrast, the term “endovascular therapy” is typically used for treatments involving arteries.

The principle behind endoluminal varicose vein treatment is that special catheters are inserted into the vein from the outside and advanced to just below the groin.

The catheters have a special probe at the tip through which heat (laser or radiofrequency energy) is applied to the vein from the inside, causing it to seal shut or be sclerosed.

The advantages of this procedure are that, once again, no skin incisions are necessary and the procedure can be performed under local anesthesia. For this reason, endoluminal varicose vein treatment is now performed almost exclusively on an outpatient basis by private practice vein specialists (phlebologists).

Endovascular therapy for an abdominal aortic aneurysm @ bilderzwerg /AdobeStock

No. Endovascular therapy requires certain conditions to be met in order to treat the vessel from the inside. These conditions usually involve the vessel’s accessibility via the groin and its shape or course.

For example, a severely kinked abdominal aorta—where the aneurysm also extends close to important branch vessels (such as the renal arteries)—may not be suitable for endovascular treatment in some cases. Otherwise, there would be a very high risk that the stent graft would not fit properly and the aneurysm would not be effectively isolated from the bloodstream.

In such cases, conventional treatment methods are usually employed, namely open surgery involving skin incisions. Unlike endovascular therapy, the open procedure can be performed almost without exception.

With open surgical procedures, follow-up examinations are often unnecessary. This is an advantage and applies in particular to the treatment of aortic aneurysms.

In contrast, frequent follow-up examinations (computed tomography, followed by ultrasound) are recommended after endovascular treatment of aortic aneurysms.

The reason for this is that stenting from the inside is more prone to displacement of the prosthesis, since it is not sutured in place.

It is essential that the patient be fully informed about this before undergoing an endovascular aortic procedure so that they can then decide whether they prefer open surgery without subsequent frequent follow-up examinations or endovascular therapy.

When is endovascular therapy used?
Endovascular therapy is used for vascular diseases that can be treated from the inside using catheter techniques. Typical indications include peripheral arterial disease (PAD), aortic aneurysms, or narrowing of the iliac and renal arteries. Thanks to the minimally invasive approach, blood flow can be restored quickly and safely.

How is the procedure performed?
A catheter is inserted into the affected vessel through a vascular access point—usually in the groin. Depending on the findings, balloons, stents, or drug-eluting balloons are used. In the treatment of aortic aneurysms, endovascular aortic repair (EVAR) is often performed, in which a vascular prosthesis is implanted. The procedure is performed under X-ray guidance and places minimal strain on the circulatory system.

What is an atherectomy, and when is it used?
Atherectomy is an interventional procedure for removing plaque from arterial vessels, for example in the femoropopliteal region of the leg. During the procedure, deposits are removed using mechanical devices or rotary instruments to widen the vessel lumen and improve revascularization.

How does endovascular treatment differ from open-surgery treatment?
Endovascular therapy is a minimally invasive procedure performed via a catheter, whereas open-surgery therapy involves exposing the vessels and operating on them directly. Studies show that the minimally invasive technique has lower complication rates and lower mortality, particularly in older patients or those with pre-existing conditions. However, close peri- and post-procedural monitoring is required.

What are the known long-term outcomes?
Recent randomized trials and clinical studies show a high success rate for endovascular treatment of vascular diseases. Blood flow remains permanently improved, and the risk of reocclusion is low. Long-term results demonstrate that modern techniques such as drug-eluting balloons, EVAR, or atherectomy enable permanent revascularization and sustainably improve patients’ quality of life.