A Gentler Fix for Broken Aortas

A Gentler Fix for Broken Aortas

It’s the sort of injury that smart trauma teams look for whenever they receive the survivors of a high-speed car crash. Though the patients’ broken bones might be instantly obvious, the deadliest culprit may lurk within—a torn aorta, either actively leaking blood into the chest or about to come apart. The complication typically propels surgeons into an urgent open-chest procedure.

But what happens when a patient is too fragile to survive heavy surgery and further blood loss?

Such a case presented itself on a Tuesday evening, when 72-year-old Raymond Sheffler was brought into the Emergency Department at Johns Hopkins Bayview Medical Center bleeding heavily from five cracked ribs and other injuries sustained in a head-on collision minutes earlier. During exams, Sheffler complained of nausea. A sharp-eyed radiologist then detected the torn aorta next to Sheffler’s heart, accompanied by a telltale bulge in the great vessel.

Sheffler’s age and other injuries made him a high-risk candidate for emergent open-chest surgery, yet his stars had clearly aligned—Bayview’s chief of endovascular surgery, Mahmoud Malas, is an expert in precisely this type of injury.

Malas quickly determined that Sheffler could die without a rapid aortic repair, which is traditionally performed by sawing through the patient’s ribs and replacing the torn portion of the vessel with an artificial graft. But Malas decided Sheffler was the perfect candidate for a minimally invasive approach much like the one used in common cardiac stenting procedures.

Malas made a 2-inch incision into Sheffler’s femoral artery. He deployed a delivery sheath into the artery to smooth the way and threaded it up close to the aorta’s injury site. He then inserted a catheter through the sheath. The tip of the catheter was equipped with a 4-inch self-expanding stent composed of a corrugated Gore-Tex hose reinforced with thin metal wire. Malas used intraoperative imaging to guide his placement of the endograft, triggering its expansion after it straddled the aorta’s rupturing section.

Once the endograft was deployed, blood again flowed securely through Sheffler’s biggest blood vessel. Sheffler was sent home three days later. An open chest procedure would’ve easily required a weeklong hospital stay and extensive rehab.

Malas says about 8,000 Americans suffer from ruptured aortas annually—mostly from high-speed collisions—and that up to 90 percent of them die at the scene. He adds that, of the remaining 10 percent who make it to the ED, half of them die because their condition isn’t recognized. (Malas credits more than a dozen of his colleagues for correctly diagnosing Sheffler’s injuries at critical stages.)

Malas says he’s bullish about the endograft procedure because it’s proving safer than open-chest techniques: It also reduces the risk of diminished nerve function to the limbs that can accompany open procedures. “This procedure only took two hours,” he says of the Sheffler case. “And he only lost 10 ounces of blood, about one-tenth of what he would have lost in an open-chest procedure.” Phone 410-550-5332 to learn more.