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Radiologist and Vascular surgeon team up to perform cutting-edge procedure

16-Dec-2015

In mid-December, a multi-disciplinary team in the RQHR did what no other region in the province is doing – a fenestrated endovascular aneurysm repair (FEVAR), an aneurysm-repair that significantly reduces the patient’s risk of mortality and essentially eliminates long recoveries.

Radiologist and Vascular Surgeon Team
Radiologist and Vascular surgeon team up to perform cutting-edge procedure

“This is a combined procedure requiring the specialist skills of a vascular surgeon and an interventional radiologist,” said Dr. Mohammed Nayeemuddin, an interventional radiologist in the Region and one member of the multi-disciplinary team that performed the Region’s latest FEVAR. “Each team member plays a critical role.”

An aortic aneurysm is a weak spot on the aorta – the largest artery in your body. Ruptured aortic aneurysms can be fatal.

These aneurysms can occur anywhere along the aorta, but when it is located near to or involves an artery to one of the major organs, like the kidneys, the repair can be challenging.

“The aorta runs through the chest and abdominal region supplying blood to all of the organs. If the aneurysm is located along the artery but not near any organs, we can use a traditional stent graft, one where we do not have to maintain the blood flow through a major artery to an organ,” explains Dr. McCarville.

This involves accessing the aorta through small incisions at the groin, accessing the femoral arteries, and using x-ray to guide the stent – a tube placed within the aneurysm to reinforce the weak aorta – into place. When the aneurysm is close to or involves a major arterial supply to an organ though, a conventional stent graft won’t work.

“This is because there are vessels branching out to provide blood supply to the organs. Using a traditional stent graft could possibly block those vessels, impairing blood flow to the organs, or the stent would not have enough of a seal to exclude the aneurysm,” Dr. McCarville explained.

That’s why the fenestrated graft is needed and the reason for the complex, cutting-edge procedure.
“A patient’s aorta is as unique to them as their finger print. So, to use a fenestrated graft we have to have it custom-designed,” said Dr. McCarville.

Using a CT scan, an image of the patient’s aorta is obtained and three dimensional images are generated, which are then sent to the graft manufacturing company to guide their technologists in making the graft. This design includes the fenestrations (holes) that are accurately placed to match the anatomy of the patient’s aorta. Each hole corresponds to the unique positioning of the patients arteries.

“The fenestrations allow us to place additional stents through the customised holes which support and maintain the blood flow through the arteries that lead to the patient’s organs,” said Dr. McCarville.

“For those who can be treated this way, it is much better option. The alternative would be to do an open repair. This surgery involves large incisions in both the patient’s chest and abdomen, which has a lot of risk and leads to weeks of recovery, and, some of that recovery time is spent in the ICU,” said Dr. McCarville.

Teamwork to get the job done

“The procedure is performed in the RGH’s Angio-Interventional Suite with high quality X-rays. The work of the interventional radiologist is to help the vascular surgeon see where the blood vessels to the kidneys and the bowel are, so that the graft can be properly placed.” said Dr. Nayeemuddin.

Although Dr. Nayeemuddin was involved in deployment of several regular aortic endografts, it was his first time doing a fenestrated graft here in Regina and he was very pleased with it.

“It was great to be involved in such an interesting procedure,” he said. “If you angle the fenestrated graft slightly incorrectly, then you literally cannot connect the vessels to the vital organs. You have to get the angles exactly right to fit the graft in the appropriate position. If you are even slightly off, you can compromise the blood supply to the important organs and risk a leak.”

This procedure requires the support of x-ray technologists and RNs. Also, the Region was required to have a proctor present – an expert in managing patients with fenestrated grafts. The proctor is there to observe, and help train the Region’s surgeons.

“We will need to do another six to eight cases under the direction of a proctor to have the skillset and have the specific equipment to do these on our own,” Dr. McCarville explains.

No new equipment was purchased for the Region to do these procedures.