Vascular Surgeons at Inova Heart and Vascular Institute Use State-of-the-Art Techniques to Expand Range of Patients Treated for Abdominal Aortic Aneurysms

The vascular surgeons at Inova Heart and Vascular Institute (IHVI) are successfully expanding the range of patients who can be treated for abdominal aortic aneurysms (AAA), a leading cause of death in the United States, through open surgery and less invasive, endovascular procedures.

According to the Centers for Disease Control and Prevention, common causes of AAA are a family history and risk factors such as peripheral arterial disease, high cholesterol, high blood pressure and smoking. AAA can also be associated with some infections and injuries. AAA is more prevalent among men as well as people ages 65 and older, with 75 percent of patients reporting a history of smoking. Patients do not typically have symptoms, although pain in the back, side, buttocks, groin or legs is sometimes reported.

An aortic aneurysm is an abnormal ballooning in the wall of the aorta – the main artery that carries blood away from the heart to the rest of the body. The aneurysm stretches and thins the walls of the aorta, which can cause them to burst and result in life-threatening internal bleeding. Aortic aneurysms can extend upward into the chest or downward toward the abdomen and pelvis. At IHVI, the techniques that surgeons use to repair AAAs are individualized for each patient and depend on the anatomy and location of the aneurysm as well as whether the patient is an appropriate surgical candidate.

Endovascular aneurysm repair (EVAR) is done via small incisions in the groin or needle punctures, through which the surgeon inserts a stent graft to repair the aneurysm. Open surgery is performed when an endovascular repair is not appropriate because of the aneurysm’s location and the other blood vessels that are involved. The open surgical approach requires an incision on the abdomen and a longer recovery; however, it is the best option in some cases. The majority of AAAs can be repaired with endovascular techniques.

“Our goal as an institution is to identify people who are at risk of AAA and to repair the aorta before it ruptures,” said Reagan Quan, MD, Medical Director of Vascular and Endovascular Surgery at Inova Loudoun Hospital, who also practices at Inova Fairfax Hospital.

“Inova offers the entire gamut of treatment options for AAA,” said Dipankar Mukherjee, MD, Chief of Vascular Surgery for Inova Fairfax Hospital, who also practices at Inova Fair Oaks Hospital. “We are fortunate to have available the latest in endovascular stent graft repair technology by virtue of participating in clinical trials evaluating the next generation of ever-improving endovascular stents. As such, we are able to offer the best repair using the optimal stent, based on a patient’s specific aneurysm anatomy.”

In August 2020, Inova was the first center in the Washington, DC region, and one of the first in the U.S., to use the Alto™ Abdominal Stent Graft System. The device differs from traditional approaches used for endovascular repair in that it uses a liquid polymer that allows the graft to be more durable and anatomically adaptive for each patient. Before this technology was introduced, some patients were not able to be treated using endovascular stent devices.

However, standard endografts, including Alto™, are not suitable for treating AAAs that have enlarged to include the arteries in the kidneys or intestines. The location of these aneurysms makes them more complicated to treat, and until recently the only option for these patients was open surgery or no surgery at all.

IHVI vascular surgeons now treat many of these patients with fenestrated endografts, which have “cutouts” or openings that correspond to the position of the branching arteries within the aorta. Without putting pressure on the aneurysm, the blood flows through the graft holes into the arteries and the vital organs in the abdomen. When compared with open surgery, fenestrated endografts can offer shorter hospital stays, fewer complications and faster recovery. Recently, the Inova team, led by Dr. Mukherjee and Kendal Endicott, MD, performed the first PMEG (physician-modified endograft) available only at select aortic centers nationwide. This technique expands the scope of patients who can be offered the less invasive endovascular approach and establishes Inova’s aortic team as leaders in the treatment of AAA.

While fenestrated grafts are used to treat AAAs that extend to the renal arteries, surgeons use iliac artery branch grafts to repair aneurysms that extend farther down toward the pelvis and lower extremities. Among their many benefits, these grafts are well suited to prevent erectile dysfunction because they restore normal blood flow to the lower body.

After endovascular repair, patients are usually discharged from the hospital the next day. They are closely followed in the office with ultrasound examinations of the repair and with CT angiography if there are any concerns. The mortality and morbidity of endovascular repair is superior when compared to open repair.

Inova’s vascular program is a recognized leader in the treatment of aneurysms. In the U.S. News & World Report 2021-22 ratings, Inova Fairfax Hospital’s AAA repair program was rated “high performing” for the fifth consecutive year and was the only program rated as such in the Washington, DC region.

“Inova’s success rate for AAA repair is excellent,” said Dr. Quan, “and most of these patients can expect to lead a high quality of life. Not only do we perform complex procedures, but we are also dedicated to training the next generation of clinicians to become proficient with these techniques.”

Illustration by Kashi Rahmani
This illustration provides a view of the pelvis and abdomen and shows an actual endovascular repair of an abdominal aortic aneurysm using a fenestrated graft to bypass the weakened area in the artery. The graft is the structure running through the ballooned area.

“We have an outstanding faculty and a supportive team that offers open and endovascular aneurysm repair, and we are proud to be at the forefront of clinical care and research in the management of aneurysmal disease,” said Richard Neville, MD, Medical Director of Inova Vascular Services, Associate Director of IHVI and Chairman of the Department of Surgery.

Both the Society for Vascular Surgery and the U.S. Preventative Services Task Force recommend a one-time AAA screening using ultrasound imaging for men ages 65 years or older, particularly those with a history of smoking or a family history of AAA. An indication for routine screening in women is not as strong but can be considered if the same risk factors are present.

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