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My name is Dr. James Black, and I'm a
vascular surgeon and endovascular surgeon here at Johns Hopkins
Hospital, and I regularly perform aortic operations on patients
of all ages and all distributions along the aortic tree.
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So an abdominal aortic aneurysm is a weakness of the abdominal aorta.
It tends to produce a dilation of the blood vessel,
whereas normally it's about the size of a garden hose, it
can grow to reach up to five, six or seven centimeters,
close to the size of a, a liter bottle of soda.
It's also the fifteenth lea, fifteenth leading cause
of death in the United States for among adults.
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There are three ways that physicians treat abdominal aortic aneurysms.
The first is surveillance, which of course is
the easiest of all ways we treat aneurysms.
Not every aortic aneurysm needs to be treated.
A lot can be safely monitored, as long
as the patient is under surveillance which can
be sometimes performed with something as simple as
an ultrasound, over a cat scan or an MRI.
The second way we treat aneurysms is with open surgery, which
has traditionally been done for the last 50 or 60 years.
Very good outcomes with expectedly a longer recovery, because of the nature of
the incisions, and the, the body cavity, and working around the whole aorta.
More recently, in the last 10 or 15 years, we've been
treating abdominal aortic aneurysms with stents which has the advantage of
a more minimally invasive approach and avoidance of the major incisions
that plagued the recovery of patients who underwent the open surgery.
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A fenestrated stent graft is a new device that builds upon a very time tested
and excellent platform that we've been using
in the United States for over 15 years.
The prior version of a stent graft was
predominantly used just below the kidney arteries themselves
and in fact, covered probably 50 to 60%
of all abdominal aortic aneurysms that we treat.
A fenestrated stent graft implies that the stent graft itself
has small windows cut into it, so that now we
can bring the stent graft up across the kidney blood
vessels themselves, thereby capturing another 20 or 30% of patients.
And now making them a candidate for an endovascular aneurysm repair, where as
previously, they would've had to undergo an
open surgery with a much longer recovery.
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The benefits of a fenestrated stent graft
really build upon the success that we've had
over the 10 or, last 10 or 15 years with a traditional endovascular aneurysm repair.
That is, we have smaller incisions, faster
recovery, and generally a much shorter hospital stay.
Most patients will be in the hospital only two or three days.
The specific advantage of the fenestrated stent
graft over what we've been doing, is that
it allows now us to treat aneurysms
that go close to the kidney arteries themselves.
And by doing this type of procedure we can keep the
circulation going to those kidneys as we're actually placing the stent.
Whereas with a traditional open surgery, we would have
had to interrupt the circulation to the kidneys for
anywhere from 15 to 30 minutes, which, with a
much higher risk for kidney failure after the operation.
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Patients who are eligible for a fenestrated aortic stent graft are
those whose aneurysms are close to the kidney artery, kidney arteries themselves.
And also have the time to wait for the device to be engineered.
All of these devices are actually built for the patient individually.
That is, once a device is made, it can't
really be used for anyone else in the entire world.
So by doing a CAT Scan before the procedure, we measure
up the stent graft specific to the patient, the patient's anatomy,
and then order it from a company which takes around four
to six weeks for the device to finally be, finally be delivered.
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The main risks of a fenestrated ader,
aortic endovascular repair is that of an endoleak.
And that is, after we place the device, that we still
see leakage around the aortic endovascular device into the aneurysm sac itself.
This is where the premium is really put
upon understanding the anatomy of the patient individually.
So if we're able to get a very good result in terms of
the fit of the stents against the patient those risks are much less.
Other risks that can occur with a fenestrated aortic
endovascular pair are mostly referred to those of the kidney.
Sometimes some of the stents that we've
put in the kidney arteries themselves can have
trouble lining up correctly, and produce kinks and
narrow the blood flow into the kidneys themselves.
At the time of the procedure we take
multiple views of those stents into the kidney
arteries to make sure that the circulation to
each kidney Is not adversely affected during the procedure.
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The recovery from a fenestrated aortic endovascular repair verses
a traditional aortic endovascular repair is not much different.
That is, the patient would come in on the day of
surgery and probably go home two, or maybe three days later.
In fact, some of our aortic endovascular procedures we can do
percutaneously and even have the patient go home the next day.
In comparison to an open procedure, it's much like apples and oranges.
An open procedure is a much longer recovery
in the hospital, usually one or two nights
in the ICU, and feeling not like one's,
like oneself for about a month after the surgery.
Final recovery from an open operation could take up to four to six weeks.
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After a patient undergoes a fenestrated aortic endovascular
aneurysm repair, they can expect to come back to
the hospital or to the outpatient clinic for a
follow-up appointment approximately four to six weeks after surgery.
That first appointment is very important.
At that appointment we would do a CAT
scan, to make sure that the aortic endovascular
repair is functioning well, and there's no sign
of any leakage, or effe, effects upon the kidneys.
The next appointment would probably not be for a year.
And at that point we would probably still do another CAT scan.
Or for those patients whose kidney function goes into the
procedure, is somewhat marginal, we might switch to an ultrasound, to
make sure that the aortic endovascular repair is functioning well,
and that there's no evidence of leakage into the aneurysm sac.
And that also the aneurysm sac begins to shrink down, which we
usually take as a best sign of durability of the repair overall.
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>> Johns Hopkins has been at the head of aortic surgery for close to 100 years.
Many of the aortic operations that occur around
the country, even around the world, have their
birth in the hands of surgeons who trained at Hopkins at some point along the way.
In terms of fenestrated aortic endovascular repair,
Johns Hopkins is one of 30 centers
around the country that has access to the technology to deliver such a device.
The team we have at Hopkins is very good at what they do.
Many people here have great interest in the patients, and
put the patient at the forefront of the decision making.
Many aneurysms will not need to be treated.
But when they do need to be treated, the team
we have here is gonna be one of the best.
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