Treatment Selection & Results

Treatment Selection & Results in Vascular and Endovascular Surgery


Aneurysms of the aorta in the chest can be lethal if undiagnosed and left untreated. The indication for repair is an aneurysm of 6cm or larger in a patient with a life expectancy of at least 3-5 years. Conventional open repair by thoracotomy carries a significant risk of death, heart attack, stroke, and paraplegia. It has now been shown that the use of a stent-graft(TEVAR) provides excellent results and with few fewer complications than open repair. For example, the risk of paraplegia is reduced from 8% in open repair to 2% with TEVAR. TEVAR can usually be performed via a femoral approach with a small incision in the groin area. For those patients with small femoral arteries, it might be necessary to place a conduit to the iliac artery in order to provide sufficiently large access to pass the device into the thoracic aorta. Placement of the conduit requires exposure of the iliac artery thru a retro-peritoneal approach via an incision above the inguinal ligament. The routine that I use is to admit the patient the day before planed operation. We then place a small drain in the back that can be used to drain spinal fluid during operation. It has been shown that the risk of paraplegia can be reduced by reducing spinal fluid pressure during and immediately after operation. The next day, the operation is done under general anesthesia. The femoral artery in the groin is surgically exposed. Asheath and guide wire are then passed into the thoracic aorta under fluoroscopic control and an angiogram is performed. This then serves as a road map for placement of the stent-graft. The stent-graft is passed into position over the guide wire and the device is deployed. A final angiogram is performed to assure a good technical result in excluding the aneurysm from the circulation. The opening in the femoral artery is then repaired and the patient is returned to the recovery room, I prefer to follow the patient in a ICU setting to monitor neurologic function. Meanwhile the patient is awake and can resume a regular diet. The spinal fluid drain is open in order to lower the pressure to 10cm of fluid for the first 24hours. After that, the drain is caped for another 24hours. If no problems, the drain is removed and the patient is usually discharged on the third or fourth post operative day and can rapidly return to normal physical activity. I usually obtain a CT scan in 6 months to check for function and to make sure that there is no evidence of endoleak. If all is well, I usually follow patients once per year with a CT scan.

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