Minimally-invasive Techniques and Custom-Made Endografts Result in Improved Outcomes

by Helen K. Kelley

New minimally invasive techniques and custom-made endografts are making a difference for high-risk patients in the arena of vascular surgery. Several of Atlanta’s vascular surgeons are performing procedures that result in improved outcomes and shortened hospital stays for patients with abdominal aortic aneurysms.

Fenestrated aortic endografts for high-risk patients

It is estimated that 1.7 million Americans suffer from abdominal aortic aneurysms, a bulge in the main blood vessel that runs through the stomach and carries blood from the heart to the rest of the body. More than 50,000 repairs are performed annually in the United States on patients with this condition.

The condition, which can be life-threatening if the aneurysm bursts and causes severe internal bleeding, is relatively common in men and those aged 65 and over. Despite this, approximately half of those with abdominal aortic aneurysms may not be candidates for traditional repairs due to other risk factors and health conditions.

Those at risk for developing an abdominal aortic aneurysm include people who smoke, have a family history of aortic aneurysms, have high blood pressure, high cholesterol or a plaque buildup in and on artery walls restricting blood flow (atherosclerosis). Infection and trauma also can cause abdominal aortic aneurysms, according to the Centers for Disease Control and Prevention.

A new procedure, a fenestrated aortic stent-graft (or endograft) can help these high risk patients get the life-saving aortic aneurysm repair they need.

“Until now, repairing complex or ruptured abdominal aneurysms was risky,” said Eyal Ben-Arie, M.D., a vascular surgeon with Piedmont Heart Institute who has a particular interest in aneurysm repair. “With this minimally-invasive procedure, a fenestrated aortic stent-graft is used to reinforce openings and maintain blood flow to vessels that lead to other organs in the body.”

Instead of making a large incision in the stomach, doctors performing a fenestrated aortic endograft make a small cut near each hip. A small, fabric tube called a graft is inserted into the arteries and positioned in the appropriate blood vessel. Once in place, the graft seals off the aneurysm and makes a new path through which the blood flows.

“Patients who get this new procedure may go home after a very short hospital stay, generally do not require an ICU stay or a transfusion, and experience minimal pain after surgery,” said Dr. Ben-Arie.

Dr. Ben-Arie performed the procedure for the first time at Piedmont Atlanta Hospital on Feb. 6, 2013 in collaboration with the hospital’s entire vascular team.

Custom-modified endografts reduce wait time for patients in need

Joseph Ricotta, M.D., of Northside Vascular Surgery, is the first and only surgeon in the United States with FDA approval for an Investigational Device Exemption (IDE) to create and implant custom-modified endografts for high-risk patients with thoracoabdominal aortic aneurysms (TAAA).  Dr. Ricotta performed his first case, as part of his new MOSTEGRA (MOdified STEnt GRAft) clinical trial, Feb. 12, 2013 at Northside Hospital-Forsyth in Cumming.

Dr. Ricotta, who can make a custom-modified endograft in the OR in as little as 30 minutes, says one of the procedure’s advantages is the ability treat patients quickly.

“We keep all the necessary supplies and tools to make the endografts on hand and ready in the OR,” he states. “When a patient is admitted for TAAA, we can make a customized graft immediately, which is especially helpful in emergency situations.”

Since the entire aneurysm is repaired from the inside of the aorta, rather than cutting open the chest and abdomen, patients have a much shorter hospital stay and a quicker recovery time. In Dr. Ricotta’s Feb. 12 case, the patient was removed from the ventilator at the conclusion of the operation before she left the operating room and went home just two days after surgery.  A traditional open surgical procedure would have left her in the hospital for more than one week and on oxygen for most of that time.

However, construction of these devices requires that they be custom-made to fit the specific anatomy of each patient.

“The kidney arteries and intestinal artery all arise from different positions off the aorta,” Dr. Ricotta explains. “Angles, curvature and locations can differ from patient to patient — no two people are the same in terms of their blood vessels and aortic anatomy.”

Ricotta says that his technique has evolved since he began making custom-modified endografts in 2007, and will continue to change as new methods are discovered.

“The foundation of what I do is the same, but the way I do it has changed a lot in the last six years. You learn over time how to make improvements,” he states. “We’re always looking fore ways to make the procedures quicker, safer and easier for the patient.”

Minimally invasive treatment for Aortic Stenosis  

With an ever-aging population, identification and treatment of heart valve disease has become a primary focus in the treatment of cardiovascular disease. Aortic valve stenosis is of particular concern given the dismal prognosis of this condition as the valve worsens.

The normal aortic valve allows blood to freely exit the left ventricle, the main pumping chamber of the heart.  In aortic stenosis, the valve does not fully open, due to heavy calcium build-up, which decreases blood flow from the heart.  Without treatment, approximately 50% of severe aortic stenosis patients will not survive more than two years from the onset of symptoms. Historically, treatment was via open-heart surgery which requires a large incision or cutting through the entire breastbone. Yet, a patient’s advanced age or the presence of other medical conditions might often preclude them from traditional aortic valve replacement surgery.

Amar Patel, M.D., an interventional cardiologist and Medical Director of WellStar Hospital System’s Structural Heart and Valve Program, along with fellow interventional cardiologist Arthur Reitman, M.D. and cardiothoracic surgeons William Cooper, M.D. and Richard Myung, M.D., offers these patients a life-saving alternative called Transcatheter Aortic Valve Replacement (TAVR).

TAVR is an FDA-approved catheter-based procedure in which the new prosthetic aortic valve is implanted via a minimally invasive approach by either going through a small incision in the groin or left chest, underneath a rib. The TAVR approach greatly increases a patient’s survival rate, alleviates debilitating symptoms, reduces the likelihood of repeat hospitalizations and improves the quality of life for aortic stenosis patients who have no other treatment options.

Dr. Patel says that performing the procedure as a team of CT surgeons and interventional cardiologists is a critical part of a successful outcome for the patient.

“We do these procedures as a team,” he states. “Because one of the most important aspects of the TAVR procedure is a true multidisciplinary approach to managing the patient.”

In comparing like patients who do undergo TAVR versus surgical aortic valve replacement (SAVR), the length of stay and recovery time is shorter with similar procedure success, stroke risk and death. However, Dr. Patel warns that the TAVR procedure is not without its own risks.

“Vascular complications were higher in the TAVR group given the large sheaths that are used during the procedure when the valve is replaced by going through an artery in the leg,” he states. “Also, medical conditions such as significant heart failure, renal insufficiency, lung disease, liver disease and frailty may adversely impact the success of the procedure or post-procedural recovery.”