Q&A Topic: Complex Aneurysms
Igor Laskowski, MD, PhD, FACS, RVI, RPVI
Q: Why are complex aortic aneurysms so hard to treat?
A: Aortic aneurysms are silent killers. You often don’t know you have them until it’s too late. If they grow beginning of the rupture and unfortunately majority of patients die before they can arrive at the hospital for treatment. So early detection and preventive treatment is the key of therapy. Even patients with small aneurysms face an uphill battle: 80% of them will grow and calls for lifelong surveillance.
Vascular surgeons must contend with significant complexity in management of aortic aneurysms. Surgical repair by means of open aortic repair is very invasive—a big operation performed on a patient who’s likely unhealthy to start. Surgeons who do this work have to be fundamentally unafraid of challenges.
Q: Can you provide a quick tour of the history of treatment?
A: Before advent of modern surgery of early 60s surgeons dealt with aneurysms in diverse ways, many of which were crude by modern standards. Open repair became standard of treatment but as we said it is very invasive. Starting in the 1990s, we saw the evolution of the first aortic stent grafts, which marks the beginning of minimally invasive aortic interventions. The first one was actually a homemade device! It revolutionized treatment and created a new area of fast developing science.
As I came of age as a vascular surgeon, I got to witness these stents evolve from ad hoc devices to commercially produced tools, which are now in their second and third generation. What previously required one of the biggest operations in vascular surgery now can be treated through small groin incisions or even percutaneously. In other words: with just a pinhole in the skin.
One has to remember that this is an evolving area. We are still awaiting results of long-term follow ups on these therapies however what we have seen so far is very promising. So we’re seeing history in the making.
Q: What are some of the recent breakthroughs?
A: We’re moved past stenting of just treating garden-variety aneurysms of the infrarenal aorta—located between pelvis and kidney arteries. We’re now in the period of managing complex aneurysms that involve renal and intestinal arteries themselves. This is technically harder since we have to maintain flow to the branching blood vessels in this area. We initially started placing small-diameter covered stents in branch vessels —in parallel to the big stent going into aorta and were early adopters of this technique at Westchester Medical Center. This fix, which is referred to as a snorkel because of its appearance served as a bridge therapy before the arrival of the first commercially available fenestrated stent graft.
With its arrival back in 2015 we again found ourselves at the forefront of therapies for complex aortic interventions. Our previous vast experience with earlier devices allowed us to quickly adopt fenestrated stent graft in treatment of our patients requiring this approach. And although this device is FDA approved the use of it is quite limited to practices and surgeons with appropriate endovascular training. Thanks to staying on the cutting edge of technological developments and with the support of our division chief, vascular colleagues, referring physicians and administration we are able to routinely offer this unique treatment at Westchester Medical Center today. At present we have successfully treated over a dozen of patients using this method and we are the only hospital north of New York City offering this treatment modality in our area.
Q: What are your hopes for the future?
A: We would like to be able to treat aneurysms located even more proximally in the aorta using minimally invasive approach. Particularly I am referring to thoracoabdominal and complex thoracic aneurysms. Traditionally, these aneurysms require open surgical approach. These operations are exceptionally complex and invasive, since you’re operating in two cavities: the chest and the abdomen. As a result, they have more complications and a longer recovery period. But what if this process could be significantly simplified? That’s our goal.
As with any new technology evaluation through clinical research is the answer. Our plan is to participate in clinical trials evaluating stents for thoracoabdominal pathology—and in cooperation with cardiovascular surgeons eventually we would like to be able to offer branched graft to our patients.
Another challenge is that all fenestrated stents are custom-made to individual patients. The downside is the wait time needed for the stents to be manufactured. We hope that in the future we will be able to use off-the-shelf grafts, and while some need for customization will remain, we may be able to use preexisting components and thus limit wait time.
Successful stent placement for repair of complex aortic pathology is just the beginning of the journey. The grafts are not welded or sewn, so a lot of things can happen over time. They can move, migrate and even come apart. Therefore we follow our patients for life and check up on them periodically with imaging studies. This close follow-up and early detection of any potential issues is the key to good long-term outcomes.
Igor Laskowski, MD, PhD, FACS, RVI, RPVI
Westchester Medical Center
19 Bradhurst Ave, Suite 3850S
Hawthorne, NY 10532