Repair of Abdominal Aortic Aneurysm Takes a Leap Forward
Date: June 15, 2013
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.
About 20 to 30 percent of patients, however, who are fortunate enough to have their aortic aneurysms identified prior to rupture can’t have the endovascular repair because their aneurysm is located too close to the renal arteries (which supply the kidneys). For them, the only option has been open surgery, which carries higher risk of heart attack and kidney failure. “In the past, we generally needed at least 10 to 15 millimeters of length between the renal arteries and the aneurysm 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 was among the first hospitals in the United States to offer 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. But it’s different from the off-the-shelf graft because of fenestrations—two tiny holes drilled into the graft to accommodate the renal arteries, and thereby allow repair of aneurysms that are even closer to the renal arteries than the previous restriction of 10 to 15 millimeters. Black and his team do substantial planning using 3-D modeling of the aorta before the surgery to ensure that the graft will be engineered to match the patient’s unique anatomy. Patients can leave the hospital three days later and resume their normal activities in two weeks, compared with a four- to eight-week recovery following open surgery. As for follow-up, a CT scan is needed one to two months after the procedure, followed by annual doctor visits.
Patients 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 Johns Hopkins, we perform close to 100 open abdominal aortic aneurysm repairs each year for patients ineligible for the minimally invasive option,” says Black. “With the new fenestrated stent graft, we can spare many of those patients from a big operation and long recovery.”