Washington University vascular surgeons at Barnes-Jewish Hospital deliver outstanding care to patients
The Washington University and Barnes-Jewish Heart and Vascular Center is a national leader in heart and vascular treatments and offers exceptional care for conditions including heart valve disease, heart failure, coronary artery disease, aneurysms, carotid artery disease and more. In 1992, Dr. Frank Veith and his team at Montefiore Medical Center are credited with the first endovascular aneurysm repair in the United States. One member of that team in the 1990s, Luis A. Sanchez, MD, FACS, is now the Washington University chief of Vascular Surgery at Barnes-Jewish Hospital. Providers at the Washington University and Barnes-Jewish Heart and Vascular Center also have access to some of the latest advances for treating aortic arch and thoracoabdominal aneurysms, giving options to patients who are not candidates for open surgery.
More than 30 years ago, the first endovascular aneurysm repair was performed, jump-starting a field that has only grown in the ability to treat patients who have complex cases with new techniques and devices such as endovascular stent grafts. Washington University vascular surgeons at the Washington University and Barnes-Jewish Heart and Vascular Center in St. Louis, were some of the first to utilize these treatments including the minimally invasive endovascular aneurysm repair. Luis A. Sanchez, MD, FACS, a Washington University chief of Vascular Surgery at Barnes-Jewish Hospital, reflects on the center’s successes, how endovascular surgery has evolved and where the field is heading.
Can you tell me a story about one of the most complicated cases you have treated and how you achieved a positive outcome?
Dr. Sanchez: A patient recently came in with a complex aortic arch and symptomatic intramural hematoma. The patient was evaluated by both cardiac and vascular surgeons. The team decided that the patient was best suited to be treated in an open surgical fashion for the ascending aortic hematoma and potential bleed.
The patient underwent the open surgical procedure where it was discovered the aorta was quite diseased, friable and thin. During the postoperative period, it was noted that the patient had developed poor circulation to the branches of the aorta due to a significant dissection and malperfusion. The patient had a CT scan within two days of the original surgery. It was noted that the patient had a complex dissection and aneurysm in the aortic arch and a dissection extending down that was leading to malperfusion.
For a patient who had surgery just a few days prior, putting the patient through another open surgery would've been a significant challenge. Looking at all the potential endovascular options, we performed an extra-anatomical reconstruction in the patient’s neck. We treated the patient endovascularly from the surgical repair that had been done by our Washington University cardiac surgeon colleagues. We were able to repair the dissection and improve the flow to all the branches further in the abdomen.
This is a great example of collaboration between specialties. We were able to leverage all the tools and expertise we have available to manage a problem that could have led to a stroke, poor circulation, and ultimately death.
What exciting developments are taking place in this field, and what can we expect to see in the future?
Sanchez: When the field began 30 years ago, the management of patients with isolated thoracic aneurysms advanced rapidly. The management of aneurysms below the level of the renal arteries, in the abdomen, and in the pelvis was also impacted by these early advancements. The technology has improved quickly over the last 20 years.
There were barriers to advancing technology for patients who had thoracoabdominal aneurysms, which included all the visceral branches, and who had aortic arch involvement. New devices have been developed over the last five years that can accommodate treating both patient populations. There has since been approval of a single branch device that now allows us to treat the entire aortic arch with endovascular techniques. Most recently, we have seen the approval of a four-branch thoracoabdominal device that we hope to continue utilizing more broadly.
Ultimately, we are now able to treat the entire aorta from the aortic valve distally to the infrarenal aorta.
Which patients are still considered better suited to open surgery?
Sanchez: Around 80 percent of our patients with infrarenal and aortoiliac aneurysms are treated endovascularly. About 20 percent of patients have anatomy not suitable for endovascular procedures and are candidates to be treated in an open surgical fashion.
In general, patients who are treated endovascularly carry lower risk for morbidity and mortality during the perioperative period. Because many of our patients are at a higher risk due to other medical comorbidities, treating these patients with an endovascular approach has tremendous advantages.
There are still specific situations where open surgical repair continues to be the best option. Patients who have aortic infections, who have aorta enteric fistulas, and patients that have failed endovascular reconstructions are all candidates for an open surgical repair. Young and healthy patients who have Marfan syndrome or other aortopathies are also better candidates for an open surgical approach. Since we do not know how the endovascular devices would behave in patients with an abnormal aortic wall, we look to open surgical repairs to give the best short-term and long-term results.
If you are a cardiac or vascular surgeon, cardiologist or internist and have a patient with an aneurysm and dissection who might benefit from a referral to the Washington University and Barnes-Jewish Heart and Vascular Center, call 314-273-7373..
