A Custom Graft Now Provides Another Repair Option for Abdominal Aortic Aneurysm
Date: October 30, 2012
Endovascular repair of abdominal aortic aneurysms has become increasingly common over the past decade, and now this minimally invasive approach is performed more often than the open surgical method because of lower morbidity and faster recovery for patients.
About 20 percent to 30 percent of patients, however, who are fortunate enough to have their dilated aortas identified prior to rupture, are not able to have the endovascular repair because their aneurysm is located too close to the renal arteries. For them, the only option has been open surgery, which carries higher risk of heart attack and kidney failure.
“We need at least 5 to 10 millimeters of length between the renal arteries and the aneurysm in order to secure the stent-graft in place in most patients,” says vascular surgeon James Black.
Only a few dozen surgeons nationwide, including Black, have been trained to repair abdominal aortic aneurysms with a new type of graft that was FDA-approved in April 2012. Johns Hopkins is one of only a few hospitals in the United States now offering this new approach to patients.
The new graft looks similar to the traditional endovascular graft made of a polyester fabric encased by a stainless steel scaffold. However, it is different from the off-the-shelf graft because of fenestrations—two tiny holes fabricated in the graft to accommodate the renal arteries, helping to keep the graft in place, as well as a scallop-shaped cut to supply blood to the superior mesenteric artery.
“We do a substantial amount of planning before the endovascular operation to ensure that the graft will be engineered correctly to match the patient’s individual anatomy,” says Black. “The planning process includes making a 3-D image and model of the patient’s aorta using computed tomography.”
The fabrication of each graft takes about five weeks, but for patients it’s worth the wait to have a less invasive repair. They can go home from the hospital three days later and get back to their normal activities in two weeks compared with a four- to eight-week recovery following open surgery. Patients have a CT scan one to two months after the procedure and then are followed annually.
Patients who are eligible for the new customized graft repair include those whose aneurysms approach within 5 millimeters of the renal arteries and have large enough vessels to deliver the stent-graft to the appropriate location.
“At Hopkins, we perform close to 100 open abdominal aortic aneurysm repairs each year for patients who are not eligible for the minimally invasive option,” says Black. “With the new fenestrated stent graft, we will be able to spare many of those patients a big operation and a long recovery.”