An aortic aneurysm is a dangerous ballooning of the body's largest and most vital artery caused by weakening of the blood vessel's walls.
The question-mark-shaped aorta extends upward from the heart then arches and turns downward toward the abdomen. Other major arteries branching off of it supply blood to the entire body.
Aneurysms can occur anywhere along the aorta. The larger they grow, the more likely they are to rupture with deadly consequences. Doctors recommend surgery when aneurysms become so large the risk of rupture outweighs surgical risks.
Janice's physicians in Newport Beach, Calif., became gravely concerned when a magnetic resonance imaging test revealed a large TAA extending from her heart, around the aortic arch and into her chest, or thorax. After weeks of careful research, they gave her the choice of undergoing surgery at a nearby hospital or coming to Houston, where a world-renowned team repairs aneurysms regularly.
"Dr. Safi has performed one the largest series of extensive aortic aneurysm repairs in the world – more than 300 over the last 12 years," said Ali Azizzadeh, M.D., medical director of the vascular laboratory at Memorial Hermann Heart & Vascular Institute–TMC and assistant professor in the department of cardiothoracic and vascular surgery at The UT Medical School at Houston.
Janice packed her bags for the long trip to Memorial Hermann-TMC.
"If you have something that isn't normal, you can't treat it in a normal way," Janice said of her decision. "My doctor's research made me feel good about coming here."
Because the ascending and descending sections of the aorta can't effectively be approached through a single incision, Safi would typically address an aneurysm like Janice's by performing what surgeons call an elephant trunk procedure.
Usually, a frontal chest incision is made to access the ascending aorta, or the part that reaches upward from the heart, and surgeons replace the diseased portion with a Dacron graft. A small, loose piece of the graft is left in the descending aorta, or the part that curves downward. The graft's shape at this point resembles an elephant's trunk.
After the patient recovers for four to six weeks, a second procedure is performed. Doctors access the descending aorta through an incision in the side. More graft material is attached to that left in place from the previous operation, and the remaining diseased section of the descending aorta is replaced.
In March, the U.S. Food and Drug Administration approved a new endovascular stent graft to treat descending TAAs. Using this approach, the doctor makes a small incision in the groin, and a tube is threaded through the large, femoral artery into the aorta. There, the surgical team places a fabric-covered metal stent. Channeling blood flow through the stent relieves pressure on the ballooned artery, preventing rupture.
While the endovascular approach is much less invasive and dramatically shortens recovery time, it does carry some risks, Azizzadeh explained. "The graft is quite large, so complications can occur in the groin artery," he said.
To avoid such risks and the need for a second surgery, the cardiovascular team combined the traditional approach with the endovascular technique for Janice's surgery.
Safi and his associate Anthony Estrera, M.D., began by performing what normally would be the first of the two elephant trunk operations, the ascending aorta repair. But instead of waiting a few weeks and performing a second procedure, Azizzadeh joined his colleagues in the operating room and placed the stent graft in the descending aorta through the open chest incision.
While the descending thoracic endograft has been placed through the groin in the past, Janice's case is believed to be the first time it has been placed through the aortic arch during the repair of an ascending aortic aneurysm.
"Our center of excellence in cardiothoracic and vascular surgery allows us to integrate advanced open and endovascular techniques to perform innovative procedures such as the hybrid elephant trunk," Azizzadeh said.
Janice was discharged from Memorial Hermann-TMC within two weeks, but since she lives on the West Coast, she remained in Houston at a long-term, acute-care facility for another couple of weeks before going home. Still, the hybrid procedure cut time off her stay, since it eliminated the need for a second surgery.
"I feel good," said Janice before leaving town, anxious to return to her active lifestyle. "I feel lucky."
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