Endovascular Aortic Aneurysm Repair

Treatment Options
There are two treatment options to repair an aneurysm. The first is traditional open surgery, which carries fairly high risks since it requires general anaesthetic and a large surgical incision and may therefore not be suitable for many elderly patients or those who have other heart and lung disease or those who have had previous abdominal surgery. It also involves long hospital stays, with time often spent in intensive care units, and long recuperation timescales, with months to recover.

The second, newer treatment is a less invasive kind called Endovascular Aortic Aneurysm Repair or EVAR. Whilst EVAR isn't suitable for all patients, it is less invasive, has lower mortality rates and, as a general rule, involves shorter hospital stays (in a general ward, rather than intensive care) and quicker recovery times (weeks, rather than months).
During EVAR, which is carried out whilst the patient is conscious (they are usually given an epidural anaesthetic), a stent graft is guided into the body via two small incisions in each side of the groin. Once inserted into the aorta, the device seals off the aneurysm. The stent graft is a tubular fabric device supported by external, self-expanding metal stent bodies.

In some patients the aneurysm also involves the iliac arteries. These are the blood vessels that go from the aorta to the legs. In such cases standard EVAR stent-grafts will block the blood vessels that branch off iliac arteries. Blocking these internal arteries can cause major problems. It shuts off blood supply into pelvis, which can cause impotence and severe buttock pain when walking. These problems are collectively known as pelvic ischaemia.

Cook's Zenith Branch Graft is the world's only endovascular graft specifically designed to treat aortic aneurysms while preserving blood flow to the internal iliac artery. This allows surgeons to position the main stent in the iliac artery and the secondary branch into internal arteries. By preserving the blood flow to these arterial branches, the graft reduces the potential for the above-mentioned problems known as pelvic ischaemia.

John's Story
John was lucky: his aneurysm was picked up early. All the more lucky since his mother and sister both died of an aneurysm, so he was at high risk from the condition. However, when he first went to see his GP in 2003 because of a pain in his calf muscle, he was initially referred to a physiotherapist for treatment. His physio immediately recognised that it was a circulation problem and he was sent back to his GP.

His GP felt the swelling of an aneurysm in John's stomach and sent him for an ultrasound scan which confirmed the diagnosis. But, as is often the case, John's aneurysm was not then at a size whereby surgery was immediately required.
He was monitored by ultrasound scan every 6 months for any changes, as is recommended. Once the swelling reached 5.6 cm in diameter he was referred for surgery. At this point an operation became especially urgent as, unusually, the aneurysm was spreading down into the iliac arteries.

Operation Day
John's operation was the first iliac repair operation to be performed in Scotland. On the day of his operation, 24th October 2007, he had an epidural at 7.30am to anaesthetise him. The operation lasted just under three hours and he was awake throughout.

John's operation was performed by Dr Fong Lau, Consultant Vascular Radiologist and Mr Stephen Kettlewell, consultant vascular surgeon. As it was a first for Fong and Stephen, the procedure was proctored, or overseen, by Mr Ferdinand Serracino-Inglott, vascular surgeon at Manchester Royal Infirmary, who as one of Europe's most experienced vascular surgeons in this area, has carried out similar operations across Europe.

Stephen made two, three centimetre long incisions in the groin. Through these he was able to expose the affected artery. Dr Lau's radiology team then passed wires and various components of the stent through the femoral artery and into the aneurysm. Actual deployment of the device took just an hour and fifty minutes.

Recovery
John came out of theatre at about 2.30pm and was in a recovery room for an hour. Since he'd only had an epidural and the operation was minimally invasive, John was moved straight onto a ward, rather than the intensive unit required after open surgery.

John's post operation treatment has been minimal. He continues to have regular CT scans and X-rays on the stents to monitor his progress. John still suffers some pain in his calf muscles due to unrelated problems with the arteries in his legs but enjoys better mobility since the operation.

The Medical Perspective
Stephen explains "It is uncommon to find someone who is suitable to have this type of operation, i.e. who suffers from both an aneurysm in the iliac artery and who is appropriate to undergo this kind of EVAR surgery. What's more, the device fitted, a Zenith Branch Endovascular Graft made by Cook Medical, is a relatively new device. We simply weren't in position to offer this a year ago.

He continues, "To perform this operation using open surgery would take at least three hours and place a great strain on the patient due to the requirement for more time under anaesthetic and increased risk of infection. What's more, the ‘mend' would not necessarily have provided patients with a trouble free future: previously, patients with this specific condition risked getting pains in their legs and buttocks and reducing blood supply to the genital area.

"EVAR is not a new technique, but it is still evolving and companies such as Cook Medical are continually producing technology that can do more complex things, in a way that improves the outcome and reduces the patient's recovery time. This is especially pertinent as most people that suffer from such conditions are over the age of 65. Anything that can be done to ease and speed recovery improves the success rates of operations like this and the patient's journey through treatment."