Vascular surgery

A less direct path yields greater benefits

Thanks to developments in technology and expertise, the field of endovascular surgery continues to advance and offer many benefits to patients. These minimally invasive procedures are performed within the blood vessels, which means they require only a small incision or no incision at all. Patients usually are out of the hospital in one or two days and back to their regular activities within a week.

Endovascular surgery commonly is used to treat aneurysm, a bulging, weak area in the wall of an artery that supplies blood to the brain; and stenosis, a narrowing of the blood vessels due to accumulation of plaque. Endovascular techniques can be life-saving alternatives, especially for patients who are older and have severe medical problems, such as coronary artery disease or chronic obstructive pulmonary disease, who could not tolerate traditional open procedures. Now, two new advances—available at Johns Hopkins Bayview Medical Center—are making these procedures safer and more effective than ever before.

Minimally Invasive Treatment for Brain Aneurysm

Decades ago, the surgical clipping technique was pioneered at The Johns Hopkins Hospital and became the standard treatment for brain aneurysm. Now, specialists at Johns Hopkins Bayview are leading the way by offering a new procedure that gives 75 percent of aneurysm patients a minimally invasive option.

Because they generally have no symptoms, brain aneurysms often are discovered when they rupture, causing bleeding into the brain or the space surrounding the brain. This can lead to stroke, brain damage or death. The main goals of treatment once an aneurysm has ruptured are to stop the bleeding and potential permanent damage to the brain, and to reduce the risk of recurrence.

To perform traditional surgical clipping to treat brain aneurysm, surgeons must remove a section of the patient’s skull, spread apart brain tissue and place a tiny metal clip across the neck to stop blood flow into the aneurysm. In contrast, the new procedure—called endovascular coiling—uses fluoroscopic imaging (a type of real-time, X-ray technology) to visualize the patient’s vascular system and treat the disease from inside the blood vessel.

Through a small incision in the groin, surgeons insert a catheter into the patient’s femoral artery and navigate it up to the head and into the aneurysm. Thin platinum coils are threaded through the catheter and packed into the aneurysm to block blood flow and prevent rupture. Stents and balloons also are used to ensure that the coils are packed tightly.

“This combination of technologies gives us tremendous flexibility to access and treat aneurysms like never before,” says Alexander Coon, M.D., one of only a handful of neurosurgeons in the country who performs neurointerventional work. “The imaging capabilities in our new neurointerventional radiology suite are unrivaled. This promotes patient safety, as well as the effectiveness of the treatment.”

The advantages of the endovascular approach include no wound healing, less pain, shorter recovery and quicker return to work and daily activities. In fact, most patients go home the day after the procedure.

Flow Reversal Technology for Carotid Artery Disease

Carotid stenting is a non-surgical, catheter-based procedure that unblocks narrowing of the carotid artery to prevent a stroke. This past fall, endovascular surgeons at Johns Hopkins Bayview were the first in Maryland to perform carotid stenting using state-of-the-art flow reversal technology. This FDA-approved cerebral protection system minimizes the risk of debris reaching the brain and causing stroke during the critical stages of the procedure.

An endoscopic approach to the carotid arteries

The carotid arteries are located in the front of the neck, and carry blood from the heart to the brain’s cerebral cortex, which controls much of a person’s daily functioning. When a person has carotid artery disease—due to smoking, diabetes, high cholesterol, high blood pressure, obesity or other factors—these arteries can become clogged with plaque. Sometimes, a piece of plaque will break off and lodge in an artery in the brain, causing a stroke.

Carotid stenting treats patients who have symptoms of carotid artery disease and a blockage of 70 percent or more. It is particularly appropriate for those who would be at greater risk with traditional carotid endarterectomy surgery due to conditions such as hypertension and peripheral vascular disease, among others.

The stenting procedure itself is relatively new, and now with the latest flow reversal technology, is safer and more appropriate for a larger patient population.

Using the new technology, surgeons insert a needle through the skin into the femoral artery and insert a wire that guides a sheath through the patient’s arterial system (see figure 1). The sheath is positioned before the blockage, and a balloon is inflated to block blood flow to the carotid arteries (see figure 2). A second sheath is inserted into the patient’s femoral vein, and the two sheaths are connected to a filter. This causes flow reversal and redirects the blood into the second sheath and away from the brain (see figure 3). There, the blood is filtered of debris and returned back to the patient’s venous circulation.

“This procedure expands the options for patients with carotid artery disease, particularly those who have severe blockages,” says vascular surgeon Mahmoud Malas, M.D., director of endovascular surgery. “Prior to the procedure, we use ultrasound imaging and angiography to measure the degree of blockage. This ensures that we are choosing the best possible therapy for each patient. This new technology is just one part of our comprehensive approach to patients who are at high risk for stroke. Our team of excellent neurologists, intensive care specialists, and vascular laboratory and radiology technologists work as a team to offer behavioral, medical and surgical therapies that modify risks and positively affect outcomes. In addition, we are part of all the major active clinical trials in carotid stenting and carotid endarterectomy, allowing us to provide the latest treatments available.”

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