A new type of graft to repair aneurysms is tested with success
Michael Lapiana, 74, with his wife, Sue. He had a fenestrated endovascular graft, a procedure for repairing abdominal aortic aneurysms.
Share with others:
Eight years ago, a routine medical checkup probably saved Michael Lapiana's life.
He had blood in his urine, so his doctor ordered a sonogram, which uncovered an unrelated abdominal aortic aneurysm. That's a weakened, balloon-like area in the lower part of the major blood vessel. Without diagnosis, the aneurysm might have ruptured, and such ruptures often are fatal.
Mr. Lapiana had had no symptoms, which is the case in three out of four abdominal aortic aneurysm diagnoses.
His doctor sent him to a vascular surgeon who wanted to do major surgery. A large incision would be opened, the aorta would be clamped off, the aneurysm cut open and a graft sewn into place to act as a bridge between the undamaged parts of the blood vessel.
The retired barber from Plum, now 74, said he "didn't want to be cut open," adding, "The way they explained it, I didn't want to do that."
Someone told Mr. Lapiana and his wife, Sue, that a UPMC vascular surgeon was doing a less invasive procedure called endovascular aneurysm repair.
They went to see Michel Makaroun, co-director of the UPMC Heart and Vascular Institute, to see if Mr. Lapiana could have the surgery in which two small incisions are made on either side of the groin. Two catheters are introduced through the incisions into arteries. Compressed stent grafts are fed into the arteries and guided by fluoroscopy to the appropriate location. They are released across the area of the aneurysm, achieving a seal above and below the deteriorated area, and redirecting blood flow away from the aneurysm through the stent grafts.
Instead of a lengthy hospital stay, the patient can go home in one or two days; recovery is a week or two instead of the six weeks of open surgery.
Unfortunately, Mr. Lapiana didn't qualify for the endovascular surgery. Dr. Makaroun informed him he had what is called a "short neck." The neck is the segment of normal aorta between the renal arteries and the aneurysm. For standard grafts to work well, the neck must be at least 10 millimeters, or about a half-inch, long. Some are shorter and will not seal properly with the standard endovascular repair, and blood continues to flow into the aneurysm, which may lead to rupture.
However, at the time Dr. Makaroun was testing a new type of graft called a Zenith fenestrated graft for manufacturer Cook Medical, which was seeking approval from the Food and Drug Administration. The fenestrated graft is custom-made to fit each patient with windows, or holes, in it that allow the graft to be placed above the renal arteries. Blood can flow from the aorta through the windows into the renal arteries.
The new graft, made of woven polyester sewn to self-expanding stainless-steel stents with braided polyester and monofilament polypropylene sutures, would work for Mr. Lapiana.
"Without the fenestrated graft he would have required the open operation. Since we had the study available, I offered him the fenestrated graft, and he agreed," Dr. Makaroun said.
Mr. Lapiana had the surgery seven years ago, went home the next day and was soon back in the restaurant he and his wife then owned. He said he has had no problems with it since, although Dr. Makaroun went back into the aorta to clean out the graft three years ago.
Mr. Lapiana was one of the first of eight total patients Dr. Makaroun operated on to implant the fenestrated graft during the study. All of them are still alive, the surgeon said.
UPMC was one of five sites, later expanded to seven, that took part in the study, he said. In April the FDA approved the fenestrated graft, and Dr. Makaroun said Cook Medical began distributing it to medical centers in June. The new graft can be used on 30 to 40 percent of patients, he said.
"We still do open surgery on a lot of patients who have short necks and do not fit the standard neck-length criteria," Dr. Makaroun said. "Now many of those patients can avoid the operation and have the fenestrated stent graft.
"And of course you have the patients who do not want [major] surgery or can't have surgery and, before, they would rupture and die. Now we can offer it to those who weren't candidates for surgery because of bad lungs or a bad heart."
He said he hopes the new stent will help to "cut down on the death rate and major complication rate."
Dr. Makaroun acknowledged that the fenestrated grafts are not perfect, and patients who receive them must undergo ultrasound checkups once a year.
"There's no new technology without some issues," he said. The grafts can move, the metal can break, and some of the small branches of the aorta can flow backward into the aneurysm, requiring surgeons to go back and fix the grafts with catheters and wires.
"But the chances of that person needing a second intervention is somewhere around 10 percent," Dr. Makaroun said. "Ninety percent have no problems."
First Published August 20, 2012 12:00 am