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Deactivating an aortic time bomb

silive.com

A newly approved medical weapon could deactivate an aortic time bomb

Published: Monday, May 09, 2011, 5:05 AM     Updated: Monday, May 09, 2011, 7:04 AM
Andrea Boyarsky
9stent.jpg
Staten Island Advance/Irving Silverstein
Dr. Jonathan Deitch meets with patient Dr. Ira Greenspan
a 62-year-old Willowbrook psychologist.
Dr. Deitch performed the Endurant stent
procedure on Greenspan's abdominal aorta.
STATEN ISLAND, N.Y. — It was during a CAT scan for a serious bladder infection four years ago that Dr. Ira Greenspun learned there was something else inside his body that needed attention.

The test detected an abdominal aortic aneurysm, meaning a balloon-like, blood-filled bulge in the wall of his aorta, the body’s main artery. 

Since the aneurysm was small at the time, the Willowbrook psychologist forgot about it and didn’t think about it again until a few months ago, when his daughter urged him to have it checked. That’s when he learned the bulge had grown and was at risk of rupture — which more often than not leads to death.

In early March, Dr. Greenspun, 62, became the third patient at Staten Island University Hospital (SIUH) to undergo Medtronic’s new Endurant AAA Stent Graft System procedure, a minimally-invasive treatment approved by the U.S. Food and Drug Administration in mid-December.

“I’ve been doing the minimally-invasive repairs in excess of 10 years and the grafts keep evolving,” said Dr. Jonathan Deitch, director of Vascular and Endovascular Surgery at SIUH, who performed Dr. Greenspun’s surgery.

“These late-generation devices are continuously being improved,” he said. “Upwards of 80 to 85 percent of patients are being operated on with this type of technology.”

The endovascular or minimally-invasive technique is used instead of an open surgical repair, a more invasive approach that necessitates a large incision in the abdomen. Typically, doctors wait until abdominal aortic aneurysms are around five centimeters before considering surgery.

The Endurant Stent Graft System increases the number of people who can undergo an endovascular procedure, according to Dr. Deitch. It is designed to fit through tight arteries and other spaces, allowing doctors to, in his words, “accommodate some tricky anatomy.”

During the procedure, an incision is made in the groin, giving the catheter and attached stent graft access to the arteries leading to the aorta. Once in the aorta, the stent graft — a flexible wire frame sewn onto a woven fabric tube — is placed in the aneurysm to create a new, permanent path for blood flow.

REDUCING PRESSURE

“What this does is reduce the pressure on the aneurysm and, by extension, the risk of rupture,” explained Medtronic spokesman Joe McGrath. “If it ruptures, people have very little chance of surviving.”

About 200,000 people develop abdominal aortic aneurysms each year; around 15,000 die from a rupture, he said. Only around 10 percent of those who experience a rupture survive.

Most ruptures are preventable, he added, although many people don’t know they have an aneurysm until it’s either found accidentally during a scan — like Dr. Greenspun’s — or they experience a rupture.

Those at greatest risk are men over 60, people with a history of smoking, family history of cardiovascular or aneurysmal disease, and prior open heart surgery.

Since the Endurant system became available, several hundred patients across the country have been treated with it each week. In addition to SIUH, the procedure is performed at Richmond University Medical Center in West Brighton by Dr. Vittorio Rotella, the hospital’s associate chairman of surgery.

Dr. Rotella performed his first procedure in late January and has done several since. The less-invasive approach is a good option for patients who are older or sick, said the vascular surgeon. It typically requires an overnight hospital stay and offers a quick return to activity, as opposed to a week or more hospital stay for the alternative treatment.

“We sparingly use the open procedure,” Dr. Rotella said. “But sometimes you have to do it open if patients don’t have the anatomy that is amenable to a stent graft.”

The Endurant procedure usually takes around two hours, he said. Afterward, patients are monitored with post-operative imaging like CAT scans or sonograms to ensure the pressure on the aneurysm has decreased. Patients typically go for follow-up every few months in the beginning and then once a year for life.

FOLLOW-UP

Dr. Rotella explained doctors are checking for stent graft migration and endoleaks, which can cause blood to flow to the aneurysm and lead to further expansion. The chances of these risks are minimal, the doctor noted, adding, if an issue arises, subsequent intervention is performed.

Dr. Greenspun considers himself lucky to have caught the aneurysm before it ruptured — it was already around six centimeters. And he’s especially grateful for the non-invasive approach: As a Multiple Sclerosis sufferer, the open procedure and its recuperation would have been a lot for his body to handle.

“Dr. Deitch was courageous to take on a patient with secondary problems, and prevent a more serious, life-threatening issue,” Dr. Greenspun observed. Of the surgery, he said, “I woke up, had no pain, just two small incisions on the top of my leg, stayed overnight in the ICU and was discharged the next day.”
    



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