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Physicians Update

 
Winter 2006: Vascular Disease

Aneurysms Repaired with Less Invasive Procedures

The detection and repair of often silent, symptom-free bulges in blood vessels continues to improve as new techniques emerge at UCLA to treat abdominal aortic, popliteal artery and descending thoracic aorta aneurysms.
Abdominal aortic aneurysm— the 11th leading cause of death in the United States—generally is discovered by accident when a patient undergoes imaging for another reason. Worst case, the aneurysm is found only after it has burst and the patient is in severe crisis, says Wesley S. Moore, M.D., a UCLA vascular surgeon and a pioneer in the repair of aortic aneurysms.
Patients who do experience symptoms often complain of back pain, particularly in the lumbar area, as well as abdominal pain. Physicians often believe the patient is suffering from gall bladder or back problems and may order scans that will subsequently reveal the problem.
Early detection and strict patient monitoring are critical to prevent
aneurysm ruptures, which are fatal about 90 percent of the time.
Simple and accurate methods of detection already exist to diagnose abdominal aortic aneurysm, an abnormal widening in the aorta usually occurring just below the renal artery. Physicians can perform physical examinations on the abdomens of highrisk populations or order an ultrasound, says William J. Quinones-Baldrich, M.D., UCLA surgeon.
Abdominal aortic aneurysms most often occur in people aged 65 and older. Males over 65 with hypertension are most at risk, Dr. Quinones- Baldrich says, and about a quarter of patients that develop these aneurysms have a family history of them. Other factors, such as smoking and chronic obstructive pulmonary disease, also increase risk.
Detecting the aneurysm early also is vital, says Todd Reil, M.D., UCLA vascular surgeon, because even those who survive a rupture repair often will suffer from serious related health problems. “This is a preventable cause of death,” says David A. Rigberg, M.D., UCLA vascular surgeon who, along with his colleagues, advocates routine testing in those most at risk. An initial screening test would indicate whether the aorta is enlarged, and therefore most at risk to rupture.
“Patients with smaller aneurysms would require follow-up imaging every six to 12 months,” Dr. Rigberg says. “Some patients, depending upon their age, might never need surgical repair.”

Aneurysms can be repaired using various surgical techniques.
Surgeons can open the abdominal cavity and clamp the aorta above and below the aneurysm and sew in a piece of plastic tubing to take the place of the weakened part of the aorta, Dr.
Reil says. It’s a major procedure that requires blood transfusion and leaves the patient hospitalized for a week to 10 days and facing six to eight weeks of recovery time. Mortality rates with this conventional method of aneurysm repair are about 2 percent to 3 percent.
A newer technique, pioneered and tested at UCLA by Dr. Moore, is less invasive. “Patients are getting the same durable repair that an open operation would provide, but with a smaller, minimally invasive incision,” Dr. Reil explains. Called an endovascular approach, this imaging-guided technique uses the arteries in the groin to access the aneurysm and remotely deploy a stent graft to substitute for the weakened section of aorta. This technique basically inserts a new lining into the damaged aortic section and keeps the blood flow from the vulnerable area. This type of repair is associated with lower mortality and morbidity, leaves the patient in less pain and facing a much quicker recovery. Patients typically spend one night in the hospital and feel better within a week.
UCLA surgeons have been performing such endovascular repairs since 1993. The procedure—first performed on the West Coast by Drs. Moore and Quinones-Baldrich— cannot be done on all patients, however, depending upon their anatomy and the location of the aneurysm, so both techniques remain the gold standard of care.
Another technique, the retroperitoneal approach, calls for a relatively short incision on the patient’s side. The repair of the damaged section of aorta is carried out without entering the abdominal cavity, so it is less invasive and patients experience a quicker recovery.

Laparoscopic aortic surgery is another viable alternative. Carlos Gracia, M.D., one of the pioneers of the procedure and director of UCLA’s Minimally Invasive Surgery Program, along with Drs. Reil and Quinones- Baldrich, are developing a laparoscopic aortic program at UCLA and have performed procedures on 11 carefully
selected patients. The laparoscopic surgery is in some cases done with the use of a robotic instrument, which can add precision to the repair and assist in training new surgeons in the minimally invasive method, Dr. Gracia explains.

Popliteal Artery Aneurysms located in other parts of the body—behind the knee and in the wall of the aorta within the chest,
specifically—are being repaired at UCLA using less invasive procedures. Popliteal artery aneurysms, located behind the knee, rarely rupture, but can form blood clots that block circulation to the leg, leading in some cases to limb loss. If a physical examination and ultrasound study reveal a popliteal artery aneurysm larger than two centimeters and a blood clot against the aneurysm wall, then it needs to be repaired, notes Dr. Moore.
The traditional approach has been to take out the saphenous vein by making a long incision in the thigh, then tying off the artery above and below the popliteal aneurysm, followed by a vein graft bypass. “At UCLA, we use a more direct and simple
approach,” Dr. Moore explains.
“Instead of the patient lying on their back during the procedure, we have him or her lie face down. We can then make a short incision behind the knee, directly over the aneurysm, and use a
short graft to repair the aneurysm.”

A review of UCLA’s long-term results using this operation shows that the outcomes are superior to those of the ligation and vein bypass procedure, Dr. Moore says. For patients at high risk of
complications from general anesthesia, another option is an endovascular approach. In this procedure that uses local anesthesia, a stent graft is delivered through a sheath inserted
into a normal artery in the thigh, which is then used to bridge and
externally exclude the popliteal aneurysm. This approach may not be as durable, since bending of the knee could crush or dislodge the support structure of the graft, notes Peter Lawrence, M.D., director of UCLA’s Gonda (Goldschmied) Vascular Center.

Descending Thoracic Aorta Repair of aneurysms of the descending thoracic aorta has also changed dramatically. In the past, the procedure required a large chest incision through which the aorta would be clamped above and below the aneurysm. While new tubing was sewn in during the surgery, some patients were put on a left heart bypass machine. “This procedure is associated with a higher mortality rate and a 10 percent risk of paraplegia,” Dr. Moore says.
The new procedure used at UCLA uses a stent graft that is deployed through a sheath placed in the femoral artery in the groin. The graft bridges the normal aorta above and below the
aneurysm. “This procedure is very well tolerated,” Dr. Moore observes. “The risk of paraplegia is one-third that of the traditional procedure and the hospital stay is usually one to two nights.”




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