State-of-the-Art Endovascular Aneurysm Repair at St. James
April 23, 2013
St. James Healthcare in Butte is performing state-of-the-art endovascular aneurysm repair surgery for abdominal aortic aneurysms.
Local vascular and thoracic surgeon, Dr. Thomas Aufiero, explained that the abdominal aorta is the artery that delivers blood from the heart to the lower portions of the body. Certain risk factors (see sidebar) can lead to the formation of an aneurysm, which is a bulging of the blood vessel wall. If the aneurysm gets too large, the widened artery can burst like an overinflated balloon, creating a life-threatening situation.
Aufiero said that unlike traditional aneurysm repair, which involves a large surgical incision, endovascular aneurysm repair, or EVAR, uses smaller incisions made in the patient’s groin to access the right and left femoral arteries. With the assistance of delivery catheters guided by fluoroscopic imaging, small sections of collapsed stent grafts are moved through these arteries and positioned in the abdominal aorta and iliac arteries below. Once in place, the sections are expanded using a spring-like mechanism, and secured forming an inverted Y-shaped endoprosthesis. There, it creates a new pathway inside the area where the aneurysm has formed —reinforcing the vessel wall and relieving pressure that could otherwise cause it to burst.
The procedure has been performed since the early 1990s and has been increasing in use ever since. Aufiero said that he has been performing the procedure for over a decade.
“In the last five to seven years we have had improvements in stent grafts, which now make the procedure available to the majority of people,” Aufiero said.
According to a recent report in the Journal of the American Heart Association, more than 70 percent of elective abdominal aortic aneurysms procedures are performed with EVAR.
Aufiero cautioned that not all patients are good candidates. Limitations include the size and condition of the involved and adjacent arteries, along with the individual patient’s health. But, for those who meet requirements, there are many benefits.
Traditional open surgery typically takes two to four hours. It requires general anesthesia and a seven- to 10-day day hospital stay. Aufiero said that patients aren’t allowed to eat for five to seven days and go through a lengthy, three-month recovery period.
In contrast, EVAR surgery takes one to three hours, uses a form of conscious sedation and has a one- to two-day hospital stay. Patients can resume eating on the same day as the procedure and have a shorter, six-week recovery period.
Aufiero said that patients with risk factors should undergo periodic screening. The larger the aneurysm gets, the greater the risk of rupture. The CDC reports that the risk of rupture for an AAA over 5 centimeters (2 inches) is approximately 20 percent.
“If it does rupture, about half of all patients will not make it to medical treatment,” Aufiero said.
The problem is that aneurysms can be silent killers.
“Aneurysms can be symptomatic, but most are not,” Aufiero said. When symptoms do occur, it is most often in the form of pain in the abdomen and lower back. Aufiero said that initial screening is covered by Medicare for those with specific risk factors.
Dr. Dennis Palmer, local radiologist, said that aneurysm screening requires state-of-the-art imaging procedures. “It’s the type of disease process that doesn’t give much warning. Unless you actually screen for them, they often go undetected,” he said.
Palmer said that screening procedures are done primarily through ultrasound, and augmented with CT scans.
Once an aneurysm measuring beyond 5 cm is found, surgery is advised. Palmer said that though the success rates of traditional surgery and EVAR are equal, EVAR is the preferred method for patients who meet procedure criteria.
“It’s much easier on the patient to have the stent grafts put in through the femoral artery,” Palmer said.
During the procedure, radiologists work with surgeons, using high resolution fluoroscopy to guide the stent graft components into place. Palmer said that follow-up CT scans are performed immediately after surgery to evaluate the placement of the endoprosthesis, which typically is just under 3 cm in length. With both traditional and EVAR surgery, Palmer said that follow-up CT scans are also performed at one, six and 12 months, and then yearly thereafter.
The follow-up protocol is used to ensure that the patient is not experiencing any complications, such as leaking of the blood vessel, breakdown or continued ballooning of the original aneurysm.
Palmer recommends a yearly ultrasound screening for those at risk, and encourages others to consider screening.
“I think everyone over the age of 65 should be screened.” he said.