MANCHESTER — The words “aortic aneurysm” aren't ones most people would welcome to their vocabulary. The aorta is the main blood vessel from the heart and an aneurysm, a bulge caused by a weak spot on the artery, can suddenly burst causing death from internal bleeding.
For patients suffering from the condition, Catholic Medical Center has introduced a surgical procedure new to the Manchester area for fixing aortic aneurysms.
The new procedure, called thoracic endovascular aortic repair, or TEVAR, allows the surgeon to work through a pinhole-size opening in the skin that closes on its own without a stitch, said Dr. Yvon Baribeau, M.D., who performed the first TEVAR procedure at CMC. Thoracic refers to the chest cavity above the diaphragm.
TEVAR replaces major surgery that required cracking open the patient's chest, just like for open heart, or bypass, surgery.
Not having to open the chest will expand the procedure to sicker and older patients and will allow patients to get treated closer to home.
Patients previously had to travel to Lebanon or Boston for treatment. Dartmouth Hitchcock Medical Center, which is a teaching hospital, can do experimental procedure, has offered TEVAR for about a decade. Elliot Hospital does not yet offer the surgery.
“One of our TEVAR's was an 87-year-old man,” Baribeau said. “He was very-high risk. He had burned-out lungs from smoking. I would not have opened his chest, but because we had the technology, we were able to do it.”
The first thoracic procedure at CMC was done in July. So far, two patients had completed two procedures with two more scheduled.
A tube inside an artery
The problem is addressed by inserting a tube, or stent, inside the artery that grafts to the artery wall and creates a stronger channel through the weakened area.
To place the stent graft into the artery, the surgeon threads a tiny needle, or catheter, up through the artery then releases it to expand like a balloon at the site of the damage.
“The important part is to eliminate the pressure applied to the weak part,” Baribeau said. “All the pressure is sustained by the graft.” After the surgery, the artery usually contracts around the stent or stays the same, he said.
Time in the hospital is reduced from about six days for open chest surgery to 1½ days for the TEVAR procedure, and recovery from the stent graft surgery is reduced from four to six weeks with open-chest surgery to one or two weeks. “About a week, you can go back to work, versus six to eight weeks,” Baribeau said.
The procedure itself is an hour using the endovascular approach, versus three hours for open-chest surgery, he said.
The procedure can also be used to repair dissections, or tears, in the walls of the artery.
The new surgery was made possible by CMC's investment in a high-quality imaging machine and operating suite that combines the ability to do the less invasive procedure with the ability to convert to full open-heart surgery in an emergency.
“Since these are dangerous procedures, you need very good imaging,” Baribeau said.
Three-dimensional images of the patient's bone structure are stitched together by software to a conventional scan of the aneurysm, which is displayed on a large monitor in the operating suite.
“As I navigate, as I want to deploy those different prostheses, or eventually a valve, I have a 3D picture of the aneurysm. That's critical,” Baribeau said.
“Precision is the key in these procedures because you deploy near the coronary artery, you deploy near the major arteries that you don't want to obstruct,” he said.
“When you deploy, it's a quarter of a second.”
“When we do this procedure, the patient is always prepped, all scrubbed as if I was to operate on him,” he said. “We work through the skin, but if there is any emergency, then we are able to convert to an open procedure.”
Dr. Benjamin Westbrook, another heart surgeon at the CMC's New England Heart Institute, will also be performing the TEVAR procedure.
CMC hopes to add another procedure for replacing damaged valves through a pinhole-size opening, instead of open heart surgery, by the end of the year.
The procedures will save lives, Baribeau said. For older patients walking around with 20-year-old valve replacements, “we will be able to deploy a valve in the valve,” Baribeau said.
Doctors closely follow aneurysm patients to assess their risk and determine when surgery is appropriate. Indicators for surgery include family history and rapid growth of a weak spot within a year. One symptom is unexplained back pain.
Once a patient has a stent graft put into an artery, he or she has to be checked yearly to make sure the graft doesn't move and leak or shrink and leak. “The drawback is we have to follow these patients for life,” Baribeau said.
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Denis Paiste may be reached at email@example.com.