A Novel Procedure Treats High-Risk Aortic Aneurysms

A combined endovascular and surgical approach (CESA) for treating thoraco-abdominal aortic aneurysms is being used in high-risk patients who cannot undergo traditional surgery.

Researchers at the University of California, Los Angeles (UCLA; USA) have so far performed the CESA procedure on 31 patients, and have reported excellent results in the first 20 high-risk patients with complex aortic pathology treated with CESA, operated on between 1998 and 2008. Ten of the patients had prior aortic grafting, one patient had a functional renal transplant, and all patients were considered high risk based on preoperative comorbidities. During the CESA procedure, the surgeon first makes an incision in the abdomen to access vital arteries stemming from the aorta. Then performs bypasses on them in order to reroute effectively the blood flow so that the flow originates from an area of the aorta not affected by the aneurysm. Prosthetic grafts are used to provide circulation to the bypassed arteries during this first part of the procedure; this allows for the eventual exclusion of the segment of the aorta affected by the aneurysm, through the placement of a tiny endovascular device during the second, minimally invasive stage of the CESA procedure. This second stage is often completed at a later date, allowing the body time to recover and adjust to the new blood-flow pattern. Working through a small incision in the groin, the surgeons thread the small, tube-like endograft through the femoral artery and guide it towards the aortic aneurysm. Once in place and released, the endograft acts much like a stent, relining the aortic artery wall, and becomes the new conduit for blood flow, closing off the aneurysm.

UCLA's 10-year experience with the CESA technique demonstrated that the procedure is safe and durable. There was no perioperative mortality, and the cumulative survival rate at two years was 76%, comparable to the results after traditional surgical repair in acceptable-risk patients. There were major complications in six patients, including respiratory failure, deterioration of kidney function, and minor heart attack, as well as paraplegia in one patient. One patient refused to complete the second stage and died five months later from a ruptured aneurysm. The study describing the technique and the 10-year cumulative results was published in the May 2009 issue of the Journal of Vascular Surgery.

"Due to the tricky position of some aortic aneurysms or the frailty of some patients, not everyone is a candidate for standard surgery to treat a dangerous aneurysm,” said CESA developer Professor William Quinones-Baldrich, M.D., a professor of vascular surgery at the David Geffen School of Medicine at UCLA. "The CESA technique avoids opening the chest, which is done during standard surgery. After the endograft is placed, the patients usually can go home two to three days later, compared with longer stays that generally accompany traditional surgery.”

An aortic aneurysm is a general term for any dilatation of the aorta, usually representing an underlying weakness in the vessel wall at that location. While the stretched vessel may occasionally cause discomfort, a greater concern is the risk of rupture, which causes severe pain, massive internal hemorrhage, and without prompt treatment, results in a quick death.

Related Links:
University of California, Los Angeles