Minimally invasive surgery techniques extended to major aortic repairs

UW physicians have employed a new minimally invasive technique to repair an aortic aneurysm: a life-threatening weakening and ballooning of the body's main artery that can burst if not repaired. The procedure, called stent-grafting, was performed for the first time successfully in Washington state earlier this month at UW Medical Center.

Vascular surgeon Dr. Ted R. Kohler and interventional radiologists Drs. David J. Glickerman and Eric K. Hoffer headed the team that used the new technique to treat William Belsky, 86, of Puyallup, a retired Army colonel with a leaking aneurysm. Belsky is recovering well and has been released from the hospital.

"Aortic aneurysms in the chest have traditionally been repaired with major surgery," said Kohler, "involving high risk of mortality for many patients, several days on a ventilator in the intensive care unit, and up to 10 days recovery in the hospital. Mr. Belsky's age and overall health made traditional surgery prohibitively risky. However, with the less invasive technique, he was off the ventilator the morning after surgery. Hospitalization for many patients could be just two or three days."

Since aortic aneurysms are generally suffered by older men with a history of smoking, traditional surgical repair involves major risks, said Kohler, with a 25 percent rate of death or major complications for repair of aneurysms in the chest.

Doctors anticipate much lower risk with the new technique, which is undergoing clinical trials at centers around the country, including the UW.

The new technique can be performed using local anesthesia. The stent graft — a Dacron or Teflon tube reinforced with wire mesh — is folded tightly within a catheter. The catheter is inserted into the femoral artery through a small incision in the upper leg and, with the aid of fluorscopy, threaded up the aorta to the aneurysm, where the stent graft is released. The tube expands and bridges the diseased segment of artery.

(In Belsky's case, general anesthesia was required, since the aorta had to be accessed through the abdomen.)

The technique is similar to that used in conventional angiography, balloon angioplasty and stenting for narrowed arteries, such as those in the heart and legs. However, a heart artery is only 2 or 3 millimeters in diameter. The aorta at the level of the chest is many times larger, about 2.5 centimeters in diameter, and may expand several-fold when diseased.

Aortic aneurysms may occur in either the thoracic aorta (at chest level) or the abdominal aorta. The new technique can be used for both. "Eventually, stent grafts may be used to treat up to 80 percent of all aortic aneurysms," said Glickerman.

The procedure performed this month was the first of what the UW hopes will be many such therapies for aortic aneurysm. The UW typically performs about 50 repairs of abdominal aortic aneurysm annually, at its three sites: UW Medical Center, Harborview Medical Center and Veterans Affairs Puget Sound Health Care System.

The UW has established a new Endovascular Surgery Program, including a new endovascular suite at the VA hospital to be in operation by March 1998, and subsequent similar facilities to be built at UW Medical Center and Harborview. The new suites will combine fully equipped operating rooms with state-of-the-art imaging facilities.

The endovascular suite at the VA was built with some $2 million in funding from the Veterans Integrated Service Network, and will treat patients from throughout the Northwest. ¶
Laurie McHale