Small incisions fix big problems:
Endovascular aneurysm repair quickly returns patient to his workshop

Houston, Texas, January 15, 2005 – Joel Laws learned about his life-threatening aortic aneurysm the way most patients do – by seeking treatment for some other problem.

Last summer, Laws went to a Longview hospital when he felt pain in his side. Doctors ordered a computed tomography (CT) scan to see if complications had arisen from recent gallbladder surgery. Instead, they found a large aneurysm.

An aneurysm is a ballooning of an artery that weakens the blood vessel’s walls. Ruptured aortic aneurysms kill some 15,000 Americans each year, making them one of the top 20 leading causes of death.

“It looked like a big old orange, all puffed up,” recalled Laws, an active East Texas retiree. At 82, his age is typical for aneurysm patients. An estimated 3 to 4 percent of people over age 65 have them.

Some patients may experience shortness of breath or pain in the back or neck, but most have no symptoms at all until the aneurysm ruptures. The condition can be treated if discovered in advance, but as in Laws’ case, aneurysms often are found when patients undergo CT scans or magnetic resonance imaging (MRI) tests for other reasons. More than 100,000 are diagnosed before rupture each year.

The larger an aortic aneurysm grows, the more likely it will burst and cause massive, often fatal internal bleeding. Doctors recommend surgery when aneurysms reach 5 to 6 centimeters in diameter. Traditional surgery replaces the affected segment of the aorta with a prosthetic graft.

With a mechanical valve in his heart and borderline emphysema, Laws was not a good candidate for general anesthesia and invasive surgery. Instead, his doctors suggested a minimally invasive procedure known as EVAR, or endovascular aortic aneurysm repair, and sent him to Memorial Hermann Hospital.

Ali Azizzadeh, M.D., joined Memorial Hermann’s team in August from the Washington University School of Medicine in St. Louis. “We offer the full spectrum of vascular diagnostic and therapeutic procedures,” said Azizzadeh, who serves as medical director of Memorial Hermann’s vascular laboratory and assistant professor in the department of cardiothoracic and vascular surgery at The University of Texas Medical School at Houston. In addition to aneurysm repair, Dr. Azizzadeh and his team manage blockages of arteries that feed the brain, kidneys and legs.

Laws remained conscious under local anesthesia as Dr. Azizzadeh performed the procedure. After making small incisions in the groin, the surgical team threaded catheters through the femoral arteries and into the aorta, where they placed a fabric-covered metal stent. Channeling blood flow through the stent relieves pressure on the ballooned artery, preventing a rupture.

“We can offer endovascular repair as an alternative to open surgery to all patients with suitable anatomy,” explained Dr. Azizzadeh. “Newer generation devices have expanded the application of endovascular repair.” For patients, like Laws, with other medical problems, EVAR is the only option.

The stakes are high when treating the body’s most vital blood vessel, so doctors don’t recommend any procedure until the risk of rupture exceeds the surgical risks. In fewer than 5 percent of EVAR cases, complications arise that require a shift to traditional, open surgery. To accommodate such cases, Memorial Hermann Hospital is outfitting surgical suites with catheterization equipment, permitting the endovascular doctors to perform both surgeries in the same room.

“We weigh the risks and benefits of both open and endovascular approaches for each patient. Most patients these days are selecting less invasive treatments. Patients who undergo endovascular repair require life-long surveillance imaging studies with CT scanning, MRI, or ultrasound,” said Dr. Azizzadeh.

A recent British study showed the 30-day post-operative mortality rate for EVAR to be two thirds lower than for open surgery, and EVAR patients typically recover much more quickly than those who have traditional surgery.

Laws befriended another patient with multiple aneurysms who underwent the traditional surgery about the same time Laws had the endovascular procedure. “I went home before he did,” Laws said. Because of his other health problems, Laws spent a week in the hospital after EVAR, but most patients check out within a couple of days.

Back home in Hallsville, Laws was soon busy again building birdhouses in his workshop and tending his vegetable garden. “I do anything I want to do,” Laws said. “I feel good.”

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