The "Gold" Standard: Fixing Aortic Aneurysms--In-Depth Doctor's Interview
Ben Starnes, M.D., F.A.C.S., Chief of Vascular Surgery at University of Washington talks about a new graft that helps aneurysm patients.
Your coworker said you have created a game changer when it comes to aneurysms.
Dr. Starnes: Since the inception of vascular surgery back in the fifties and sixties we as vascular surgeons have been faced with patients presenting with aortic aneurysms. Aneurysms are a widening of a blood vessel and they can go on to become large enough where they burst or they rupture and patients usually don’t do so well when they rupture. In fact, the mortality rate for patients presenting with ruptured aortic aneurysms has been routinely in the forty to fifty percent range for the last twenty five years. With new techniques in treating these aneurysms again to prevent death due to rupture we have been able to lower that mortality rate for the first time in twenty five years to below twenty percent.
What was the key to doing that?
Dr. Starnes: The key to doing that was to set up a process here at Harborview Medical Center and UW Medicine to implement a minimally invasive procedure where we actually keep the patients awake under local anesthesia while we’re fixing their ruptured aortic aneurysm. We use exactly the same stent grafts that we would use to treat a patient with an asymptomatic aneurysm that was coming in for an elective repair but we use that in an emergency setting. Now that takes coordination of care, it takes a finely greased team to kind of pull that off in a very brief period of time because we don’t have that long to treat a patient that’s in hemorrhagic shock.
So what about people who come in and they have a slow growing aneurysm?
Dr. Starnes: Right, so there was a small percentage of patients that we could not treat with these minimally invasive techniques and that’s why we came up with the idea of PMEG. And PMEG is physician modified endovascular grafts. And what we’re able to do is to actually un-sheath sterilely a conventional stent graft that would be applicable to a large number of patients. And actually cut holes in the sides of the graft to be able to treat more patients by going higher in the aorta.
But you’re the only person in North America who is doing this.
Dr. Starnes: Well there are other people that are kind of working with this but I’m the only one that’s working directly with the FDA in doing physician modified endografts.
How did you come up with this idea?
Dr. Starnes: Well, fenestrated techniques go back in to the late nineteen nineties in Australia. There were a couple of pioneers that really were pushing the envelope and started to do this. And some of these grafts are available throughout the world but they take a period of months to manufacture. Whereas we are able to create the graft on the back table immediately while the patient is brought in to the room.
And how do you create it?
Dr. Starnes: Well we actually use a software program where we take a patients CT scan images and we get precise measurements down to the tenth of a millimeter as to where those branch vessels are and we figured out how to transfer that on to an existing graft and really customize the graft for the patient.
I’m getting a picture in my head where a normal stent would just cut off all those.
Dr. Starnes: That’s right. In order to be a candidate for an endovascular aneurysm repair you have to have certain anatomic features. You need to have a landing zone below the level of the arteries that feed the kidney and you have to have landing zones down the iliac arteries. And most patients that are ineligible for a conventional repair usually have very short necks where if we were going to put a stent graft in would have to cover the arteries that feed the kidneys or the arteries that feed the bowel. And patients don’t do well when you cover the arteries that feed the kidney or the bowel because they’ll go in to renal failure and without blood flow to the bowel the patient will die.
Let’s talk about Betty what was she like when you first met her?
Dr. Starnes: So she’s an elderly woman she has some other medical co-morbidities that do not make her a candidate to undergo a standard open abdominal operation. And she is not a candidate for a standard minimally invasive endovascular procedure and so we enrolled her in to our PEMEG trial in order to be able to prevent death from rupture of this aneurysm. And we were able to go up and cover one of her renal arteries with a fenestrated PEMEG graft and then stent in to that renal artery.
So she’s completely fine now?
Dr. Starnes: Yes, she’s great and actually in one year after completing this procedure she has decreased the aneurysm sack size down to where it doesn’t even appear that she has an aortic aneurysm anymore.
So what was her option?
Dr. Starnes: Well her options were few. She could do nothing in which case her risk of rupture with a greater than six centimeter aneurysm was on the order of twenty percent per year. And so she was facing anxiety over living with this aneurysm knowing that at any time it could rupture and she would succumb to her aneurysm.
So there was no other fix for her?
Dr. Starnes: There were no other options other than to do nothing.
I’m picturing you in the operating room cutting little holes in the stent just to allow openings to the artery right?
Dr. Starnes: Yes. So, we un-sheath the graft and we use calipers, fine calipers to measure from the edge of the fabric material down to where we want that hole to be. And then we use an opthamic bovee, a cautering device to actually heat up a tungsten wire and to actually burn a hole in to the fabric between a few of the stents. And then we sew a gold, a solid gold marker around that fenestration which allows us to see it on screen to be able to manipulate the device and then to maintain profusion in to that vital blood vessel.
What’s that like knowing you can be changing the game just like you said?
Dr. Starnes: Well that’s why I do what I do. I mean that’s why I jump out of bed every morning and come in to work because it’s exciting to be in this field. It’s one of the most exciting surgical fields there is today.
Did your time in Iraq help you push forward any of these advances, I mean because of the emergency room the quick response that you needed?
Dr. Starnes: Yes, my experience in the military was a great experience. I had fifteen years, I had an honorable discharge as a Lieutenant Colonel in 2007 and I had three combat tours one to Kosovo and one to Iraq. I’m very proud of my service to my country and I think that I was able to learn a set of skills that was not necessarily technical skill but survival skill if you will in terms of not being shy to turn away from emergent situations. And also being able to cope with pretty challenging and I guess stressful environments where working in a major trauma center like Harborview is a luxury compared to working on the battlefield.
Do you want to talk about the recovery difference between traditional surgery? What about for Betty?
Dr. Starnes: Betty was not a candidate for an open surgical repair because her mortality was excessive with an open repair. But if she had undergone an open operation her recovery time would be on the order of weeks to months where she would be in the hospital for about seven to ten days to include three or four days in the intensive care unit. And then it would probably take her on the order of three to six months to fully recover from the operation and some people have told me that it took them an entire year to recover. Whereas with the minimally invasive approach like PMEG the patients can be done under local anesthesia and they can actually go home the day after the procedure and they’re back to full recovery within a week.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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