www.IdeasForSurgery.

com
Further…the future ain’t what it used to be.

April 5, 2007

Albert Einstein & Aortic Abdominal Aneurysm (AAA)

What would Albert Einstein do if he had another abdominal aortic

aneurysm in 2007? Would he opt for a traditional open surgical repair or
undergo endovascular repair with a minimally invasive stent-graft? Or
would he wait with the procedure until we come up with a better way for
a safe, less-invasive and permanent fix?

Picture: perhaps the best known AAA patient: Albert Einstein

In 1948, when Albert Einstein was the world’s most famous scientist, he
underwent state-of-the-art AAA treatment at that time: his “large” and
symptomatic AAA was cellophane wrapped. And sure enough, Albert
Einstein survived the major procedure for 61⁄2 years before passing away
due to a fatal AAA rupture in 1955. Because Albert Einstein decided to
refuse another painful major operation, he did not benefit from the brand
new technique of opening the aneurysm sac and replacing the
deceased part of the aorta in sewing in a Dacron tube graft, a technique
developed in the 1950s. Due to the invasiveness, high mortality rate,
prolonged pain and other adverse effects of this open surgical technique,
there have been recent attempts to treat AAA with minimally invasive
procedures.

And today with state-of-the-art, less invasive AAA repair devices like
covered stent-grafts and endoluminal delivery devices, would Mr. Einstein
again reject a recommended urgent treatment on the grounds of the
reported clinical failures and limitations of endovascular AAA repair? Or
would he change his mind and test his good luck, trusting that the new
stent-graft AAA repair technique has received early acceptance by
many vascular and interventional specialists and is used with increasing
frequency?

To answer these questions it might help to determine how to define and

evaluate the likelihood of success with the endovascular AAA repair
technique. Unfortuanately, periprocedural death, early or late conversion
of endograft repair to conventional open surgical repair, increase in
maximal AAA sac diameter of 5 mm or greater after endograft
exclusion, and AAA rupture after endoluminal aneurysm treatment are
clinical failures reported by physicians doing the stent-graft repair. The
cause of all these failures seems to be for two perceived shortcomings of
covered stent-grafts: endoleak and inferior durability resulting in migration
of the device. On top of the bad news, endoleaks may result in an
adverse event such as aneurysm sac growth, late conversion to open
repair, or rupture of the AAA, which was the cause of death of Mr.
Einstein, who objected to the call of a reintervention due the clinical
problems of the AAA repair technique of his time.

The frequency of secondary interventions to repair a stent-graft may be

concerning to a patient recently diagnosed with the disease and
generate uncertainty about the proper role of endovascular AAA repair.
Albert Einstein might have investigated the “secondary outcome success”
of these reinterventions and carefully examined the concept of “assisted
patency” in stent-grafts as a principles of vascular surgical care. Mr.
Einstein would have probably been reminded that it requires quite a long
time to determine with certainty the benefits of a new method of a AAA
treatment and usually longer still to be certain of the harmful
disadvantages.

The importance of stent-graft durability cannot be overemphasized

considering the SAAAVE law being in effect starting January 2007. The
prevalence of AAAs found in population-based ultrasound screening
studies from various countries ranges from 4.2-8.8% in men, and 0.6-1.4% in
women. Mandatory screening for AAA during the “Welcome to
Medicare/Medicaid exam” for 65 year old senior citizens of the USA may
lead to a large number of patients with clinically significant aneurysms.
This new relatively young group of AAA patients are different from the
elective group of elderly, many 85 years and older, who choose stent-
graft repair techniques as a more doable operation considering most
have overt comorbid chronic medical conditions. No longer will vascular
surgery be called “the surgery of ruins” – the patient population will be the
aging baby boomers with a life expectancy of more than 20 years. This
new AAA patient population will carefully consider their choices, and
weigh their decision as a “trade-off” between the benefits of opting for
the less invasive stent-graft procedure with the consequence of a less
certain and less permanent repair and a higher rate of reintervention, on
top of the need for lifelong follow-up.

There is no doubt in my mind that an endovascular aneurysm repair

technique holds many promising advantages and that innovations in the
field and further advances in technology will continue to widen
application to patients that are currently excluded from the procedure
due to anatomical limitations. However the second and third generation
stent-graft devices still seem to have considerable difficulties to cope with
changing AAA sac morphology, a major mode of late failures and
complications. Suprarenal fixation of stent-grafts seems to fail in the
treatment of with short infrarenal necks, and endoluminal stapling and
fixation techniques have not produced promising clinical results. What we
need are methods and devices to improve security and reliability at
endograft attachment sites and endografts that are more durable. This
can probably not be achieved in an endoluminal fashion.

The possibility of a new hybrid surgical approach that is less invasive than
open AAA repair and combines all advantages of endoluminal and
laparoscopic surgery has generated a lot of nervous excitement. The less
invasive combined laparoscopic and endoluminal approach may be
applied to management of persistent Type I or II endoleaks by means of
banding, automated suturing and endoluminal graft delivery. The
excitement is fueled by the fact that this hybrid approach would get rid of
the stent inside the endograft and therefore is applicable to all the
patients who currently do not have the suitable anatomy to be
considered for endoluminal repair. Ongoing research is being conducted
to create protocols that support new technologies.

AAA repair needs progress as more and more AAA patients may think
twice about the current stent-graft devices and more and more
physicians may find themselves without stent-graft patients.

K.T.

No Rights Reserved. No One Owns It. Everyone Can Use It. Anyone Can Improve It.