For the Smoker, a Chimney Graft
Date: February 28, 2011
The patient was in a bad mood, but Johns Hopkins vascular surgeon Christopher Abularrage thought she had a certain something. She was in her 70s, a smoker with bad lungs. She had advanced heart disease with pronounced heart failure and a feeble ejection fraction of 20 percent. But the more urgent detail was the ballooning aneurysm in her upper abdominal aorta, which was situated dangerously close to the takeoff junctions of both renal arteries.
A phalanx of doctors had pronounced the woman ineligible for anything resembling an open surgical procedure. But to Abularrage, the key ingredient was that she wanted to celebrate her next birthday with her husband, kids and grandkids.
He also thought this patient was a promising candidate for a complex hybrid procedure that combines an artful blend of retooling native tissues and configuring the latest covered stent graft materials in a way that could address difficult aneurysms.
In the case at hand, the aneurysm had dilated right up to the renal arterial junctions, denying surgeons a viable stretch of arterial “neck” tissue into which they might securely extend a normal artificial endograft.
Abularrage thought he had a solution. In a series of exchanges with the patient, he took pencil and paper and sketched out a standard endograft that he could construct to run through the aneurysm, one that could be partnered up with two “chimney grafts” to extend into the openings of the patient’s renal arteries. All of the new plumbing would effectively bypass the diseased aorta while employing enough radial pressure within her receiving vessels to make a seal.
Abularrage knew his biggest challenge was going to come preoperatively, when he would use advanced 3D imaging techniques to carefully measure all the patient’s critical vascular dimensions in a bid to tailor his artificial graft elements into perfect fits. “Ninety-five percent of the procedure,” he says, “is done before you enter the operating room.”
The actual OR time was about four hours. The critical moment came with the completion of the angiogram, when Abularrage and his surgical associates could verify that all of the vessels filled properly with no leaking around any of the grafts, effectively nullifying the now-deflated aneurysm sac.
It was not until his morning rounds on post-op day two that Abularrage learned of the patient’s reaction, when she groggily offered him a smile. “I can’t believe I made it through,” she said. “Thank you.”
Abularrage expects such complex cases to come along less than a half-dozen times per year, but he believes the essential principles will extend to many more procedures. “I’m tailoring the procedure to the patient,” he says, “to get each one the best possible outcome there is.”