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When it comes to the aorta—the main artery that takes blood away from the heart to the rest of the body—any condition is challenging. But when the weakened area, tear, or degeneration of the aorta occurs in the chest and abdomen or pelvic area, we classify it as a complex aortic disease.
Problems such as aortic aneurysms, tears, ruptures, dissections, ulcers, and connective tissue disorders often occur in patients who may be poor candidates for open surgery. So, they need a specialized, minimally invasive procedure. Using fenestrated and branched endovascular aortic repair (FEVAR/BEVAR), I can implant a device that repairs the aortic pathology using stent grafts, without the need for big incisions or the physiologic stress of open surgery.
In most cases, anatomic location is the deciding factor between traditional surgery or an endovascular procedure, which uses tiny incisions and the body’s blood vessels as the route to repair the aorta. If we can say “yes” to any of these questions, complex FEVAR/BEVAR endovascular repair may be the best route:
- Is the patient too weak or ill to survive open aortic surgery?
- Is the problem area close to important blood vessels, such as the visceral or cerebrovascular vessels?
- Is there very little healthy tissue remaining on which to attach a stent graft?
Devices used in fenestrated and/or branch technology are tailored to the patient’s anatomy. Two of the more common procedures we perform in the MedStar Heart & Vascular Institute include:
- Fenestrated aortic aneurysm repair surgery (FEVAR): A mesh-supported fabric tube (stent graft) supports weakened areas in the artery. Blood supply is preserved through strategically placed “windows” (fenestrations) in the tube that are bridged into the respective blood (target) vessels using additional stent grafts.
- Branched endovascular aortic aneurysm repair (BEVAR): A stent graft bridges the gap between the aorta and target vessels when the aorta is too wide.
I am one of a handful of vascular surgeons in the U.S. with an investigational device exemption (IDE) for aortic devices, and the only female surgeon to date. I have the expertise to not only implant these devices, but also design and assemble them to fit a patient’s aorta in a minimally invasive manner.
What to expect at your visit.
We receive many referrals from community vascular surgeons. Patients who come to me are often past the shock of their diagnosis but concerned about going to a specialty center instead of their normal hospital.
We counter this apprehension with knowledge. I like to draw out the patient’s aortic anatomy, and how a custom device and procedure might correct it. Then, I send the drawing home with the patient to show loved ones and help them get comfortable with their surgical plan.
We encourage patients to write down any questions they or their family have so we can give them answers by phone or at their next visit. Patients have said they appreciate the drawings as it helps simplify the understanding of this complex disease process.
“Sketching out a patient’s complex #AorticDisease helps them and their loved ones visualize the treatment plan and think of more questions for informed decision-making.”—Javairiah Fatima, MD: https://bit.ly/3utIhoC.Click to Tweet
Elite surgical teamwork, in and out of the OR.
MedStar Health’s multidisciplinary aortic team is exceptionally well-equipped to provide complex patients with holistic care.
I trained in vascular surgery at Cleveland Clinic which is affiliated with the MedStar Heart & Vascular Institute through clinical care and research. Then, I completed additional fenestrated and branch technology training at Mayo Clinic.
However, even the most skilled surgeons need an elite team, top-of-the-line resources, and a sophisticated infrastructure to give patients the best outcomes. MedStar Health offers everything our patients with complex aortic conditions need, including:
- Close collaboration with the cardiac surgery and thoracic surgery teams to provide the safest, most effective surgical outcomes.
- Dedicated anesthesia and intensive care teams with advanced training in caring for patients with complex aortic disease.
- Pre- and post-surgical support, including nutrition, patient navigation, and cardiac rehabilitation.
MedStar Health is one of just a handful of Complex Aortic Disease centers in the U.S. Strategically positioned in the Mid-Atlantic, we are within two hours of travel for patients from Virginia to Washington, D.C., to Baltimore. The next closest centers with similar services are in Boston—too far for very sick patients to travel.
Planning is paramount for device design and surgery.
When a patient decides to have surgery, we start planning their procedure by ordering a CT scan of their chest, abdomen, and pelvis. Then, we import the patient’s imaging into a special software called TeraRecon Aquarius.
This software helps create a “center line of flow” in the patient’s aorta—it essentially “straightens out” the aorta visually so we can determine all the aortic measurements with precision.
Using the software, we can take very fine measurements of the patient’s aortic arc length, where fenestrations and branches will need to be made, and distances between the diseased segment of the aorta and nearby important structures, such as the blood vessels that feed the brain, intestine, or kidneys.
On the day of surgery, we use those precise measurements to create the patient’s personalized aortic device. We cannot form the device in advance—there is no sterile storage option once it has been assembled.
Creating individualized aortic devices.
While the patient is being prepped for surgery, I work at a sterile back table in the operating room, creating and assembling their device. Once the patient is ready, we make one or two small incisions in their groin. Then we insert a catheter—a long, thin, flexible tube (sheath)—into a large blood vessel called the femoral artery.
We place the device through the sheath and, under CT-fusion image guidance, place the device accurately at the intended location. CT-fusion allows us to use lower levels of contrast dye and radiation during surgery. While both are safe, lowering contrast/radiation levels may reduce patients’ treatment time, financial obligations, and potential side effects.
Once we are in position, we deploy the stent-graft in healthy aortic tissue. Like a hand in a glove, the device perfectly matches the patient’s anatomy, closing functional gaps caused by their disease.
Recovery from endovascular aortic surgery.
Compared with traditional surgery, patients typically go home within a few days rather than weeks—with only a few small incisions and their aorta repaired. Minimally invasive endovascular procedures reduce the risk of post-operative complications, such as infection and decreased muscle tone from being laid up in the hospital.
These devices can last the patient’s lifetime and are a safe, effective pathway for patients who, in the past, would have been told they were out of options. We can give patients more active years of life with manageable follow-up.
While patients are more than welcome to travel to our offices for follow-up care, we often meet with patients and their local cardiovascular doctors by conference call, exchanging imaging results through our secure messaging system. Telehealth has given patients even more valuable time back, as well as the comfort of getting specialist care close to home.
We form lifelong relationships with our patients, and we enjoy hearing about milestones they were able to meet since their procedure: welcoming grandchildren, seeing their kids graduate college, retiring on their terms. Plus, we give patients and their doctors our cellphone numbers so they can reach us at any time with questions or concerns.
The future of complex aortic disease treatment.
Participating in clinical trials keeps our team on the leading edge of the latest technology and approaches. Specialists across our team are involved in nearly every ongoing branch and fenestrated technology trial that involves the aortic arch or thoracoabdominal aorta.
We also conduct many of our own clinical studies, which requires exceptional organization, communication, and top-notch facilities. For example, as part of my IDE, we are conducting a clinical research study of the quality of life of patients who receive a fenestrated or branch device over a five-year period. Specifically, we are working to determine the lowest levels of contrast dye and radiation we can use during treatment and follow-up to give patients the best outcomes.
All aortic conditions require expert care. But for particularly complex cases, getting personalized treatment from a team of experts soon after diagnosis can offer patients a longer, healthier life.