Heading Off a Hidden THREAT :
A Proven Surgery and Promising New Alternative Help Physicians Defuse
Robert A. Hieb, MD
Medical College of Wisconsin interventional radiologist
Gary Seabrook, MD
Medical College of Wisconsin vascular surgeon
Recognized in Milwaukee Magazine’s July 2004 issue as a “Top Doctor."
Kellie Brown, MD
Medical College of Wisconsin Vascular Surgeon
Recognized in Milwaukee Magazine’s July 2004 “Top Doctors” issue as an “up-and-comer” in vascular surgery.
What happens when the largest artery in the body swells up and bursts? Not surprisingly, the result is often death. “Of all the people who suffer this kind of rupture, half do not make it to a hospital,” says Kellie Brown, MD, Medical College of Wisconsin vascular surgeon. “Of those who get to the hospital, half never get out.”
Jerry Behling, a 70-year-old Wauwatosa resident, is one of those who made it out of the hospital to return home. His story begins on a quiet Sunday evening late last August:
“I was sitting in the living room with my wife and daughter-in-law. I remember getting up, but I didn’t feel anything unusual. Then, I suddenly felt a piercing pain—as if there was an ice pick in my stomach—and I dropped to my knees. I felt more pain and I dropped on my belly. My wife called 911 and the paramedics came. I remember people working on me, and I vaguely recall leaving the house. Then I got to the hospital. I don’t remember anything until the next morning.”
Behling had an abdominal aortic aneurysm, an abnormal bulge in the section of the aorta (the body’s largest artery) that runs through the belly. Because his aneurysm was never diagnosed, no one knows exactly how big it was when it ruptured. According to Medical College of Wisconsin Vascular Surgeon Gary Seabrook, MD, the aorta is normally abouttwo centimeters wide. “Typically,” he says, “aneurysms rupture after they become larger than six centimeters.”
Abdominal aoritc aneurysms are six times more likely to occur in men than in women and tend to pop up after the age of 55. Additional risk factors for the abdominal aortic aneurysm (“AAA” for short) include high cholesterol, high blood pressure and smoking. Genes are also a factor. “If you have a first-degree relative who has had an AAA, you are also at high risk,” says Dr. Brown. “Among male smokers over the age of 50 who have hypertension, probably 10% have an AAA.”
These aneurysms are a “stealth threat,” because they send out few warning signals. “For the most part, an AAA is not symptomatic,” says Dr. Seabrook. “If the aneurysm is pushed against the spine, they will sometimes have chronic back pain. If a person is relatively thin, a doctor could potentially feel it by physical examination.” Most abdominal aortic aneurysms are discovered only when they show up on an ultrasound test or CT scan for an unrelated issue.
Some aneurysms are too small to warrant treatment. The best course is simply to keep an eye on them. As a general rule, action is advisable when the bulge reaches 5-1/2 centimeters. The only treatment for AAA is surgery.
Dependable Surgery, Difficult Recovery
The traditional AAA operation is simple to describe. The surgeon makes a long incision in the abdomen and then moves the intestines aside to expose the aorta. Next, the aorta is clamped above and below the aneurysm. The surgeon then cuts away the bulge and sews a synthetic tube-shaped graft in its place.
“The upside of this operation is that it is very dependable,” says Dr. Seabrook. “The aneurysm is no longer there and the synthetic material lasts forever. The downside is that there is this big incision and lots of disruption to the normal body physiology.” He points out that there is a small risk of complications, the most common problem being heart attack. In addition, recovery time is long — a week or more in the hospital and several months at home before the patient begins to feel well again. “This is a huge operation and your body is going to take some time to heal.”
When the surgery takes place under emergency conditions — like what happened to Jerry Behling — recovery is harder:
When he arrived at Froedtert & Medical College, Behling had no blood pressure. In a four-hour surgery, Dr. Brown placed a life-saving graft. However, due to swelling from intravenous fluids (essential due to blood loss from the rupture) the incision had to remain open for several days. Encased in a special surgical cast, Behling spent time in intensive care and two days later, surgeons successfully closed the incision. Behling began the long road to recovery.
Promising New Approach
Although Behling came through the rupture and the surgery remarkably well, his recovery was still difficult. The truth is that even under non-emergency conditions, open AAA surgery is traumatic. Until recently, it was the only option for people with this life-threatening condition. Now, many patients have a new alternative—a minimally invasive procedure that puts much less stress on the body.
The new alternative is called endovascular repair. The most remarkable thing about this procedure is what it does not include—a large incision. Instead, physicians make two small incisions in the groin area. Using imaging, physicians guide a tiny canister containing a collapsed graft through the blood vessels to the site of the aneurysm. When the device is in the right position, the physician pulls a “rip cord,” releasing the graft.
The graft is custom-made for each patient based on measurements previously collected from a CT scan. When the procedure is complete, blood flows through the graft, relieving pressure on the bulging section of the artery.
The biggest advantage of endovascular repair is recovery time. “Most people go home in a day or two and are virtually back to normal in a couple days,” says Dr. Seabrook. “The downside is the risk of the aorta changing configuration over time.” To make sure the graft stays in place, the patient comes in for a CT scan at least once a year. If a shift occurs, surgeons can usually insert small bands to correct the problem.
Weighing Pros and Cons
“Both techniques have advantages and disadvantages,” say Dr. Brown. Although new endovascular repair leads to a much easier recovery, it is not quite as “durable” as an open procedure. Re-intervention (to correct slippage) is necessary about 20 - 25% of the time. In addition, there have been rare cases of rupture occurring in spite of the repair. “Statistics say traditional aneurysm repair is still the best way to treat the problem long-term,” says Dr. Seabrook. “If you’re 62 years old and are in perfect health and aren’t at risk for having a heart attack or other complications, you should probably still have an open aneurysm repair.” Still, he acknowledges that patients find the alternative procedureextremely attractive. “It’s hard to convince people to sign up for something that’s painful and irritating.”
On the other hand, outcomes for endovascular repair are likely to improve. “It is a relatively new technology,” says Dr. Brown. “The device itself continues to be modified, and new designs are coming out relatively frequently.”
Doctors at Froedtert & Medical College have been closely involved in evaluating endovascular repair. They participated in early trials for the procedure and are currently taking part in a landmark study sponsored by the Veterans Administration Cooperative Studies Program.
One interesting aspect of new endovascular repair is that it calls upon the expertise of two different departments — Vascular Surgery and Interventional Radiology.
Vascular surgeons use traditional open surgery techniques to treat diseases of the blood vessels. In addition to Drs. Seabrook and Brown, the Froedtert & Medical College Vascular Surgery Program includes Robert Cambria, MD, Jonathan Towne, MD and Medical College of Wisconsin interventional radiologists William Rilling, MD and Robert A. Hieb, MD.
Each week, these physicians meet to go over case histories for patients with vascular disease. Working together, they reach a consensus on the best method for treating each patient. Some patients need open surgery. For others, a minimally invasive procedure will provide the best outcomes. Other cases call for a combination of the two approaches. “Ultimately,” says Dr. Hieb, “the patient benefits because he or she gets the right operation.”
When it comes to AAA, roughly half of all patients are found suitable for endovascular repair, says Dr. Hieb. In the procedure itself, vascular surgeons and interventional radiologists work side by side. “Endovascular repair,” says Dr. Hieb, “is a true collaborative effort in which the skills of both sets of specialists are put to use.”
A Time to Celebrate
Few people appreciate the skills found at Froedtert & Medical College as much as Jerry Behling. Recently, he and his wife, Pat, were busy planning a summertime celebration to toast their 45th wedding anniversary, mark several family births and birthdays—and give thanks for Jerry’s against-the-odds recovery and return to health.
Behling is especially thankful to Dr. Brown and everyone else who helped him get back on his feet.
“They really went out of their way to take care of me. They got me well, and that’s the key thing.”