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Experts in complex aneurysm provide comprehensive treatment

By Kirk Hance, MD, vascular and endovascular surgeon

hance-kirk-ZZX03056An aneurysm – a weakened segment of the arterial wall that bulges outward – can occur in any major branch of the body's system of blood-carrying arteries. Because complex aneurysms rarely present with warning signs, managing risk factors and closely monitoring diagnosed aneurysms are critical in avoiding damaging or fatal rupture.

Smoking and high blood pressure increase patients' risk of developing aneurysms. The risk of major arterial rupture, which can occur anywhere in the body including the brain, abdomen and chest, is related to the size of the aneurysm and rate of growth. Lung disease and a family history of aneurysms also increase the risk.

Monitor and manage

At The University of Kansas Health System, we focus on monitoring aneurysms until the risk associated with rupture outweighs the risk associated with repair. The most common location of an aneurysm is in the abdominal aorta below the renal arteries. Abdominal aortic aneurysms grow, on average, at the rate of ½ centimeter per year. We usually recommend intervention at 5 to 5½ centimeters in diameter.

Our vascular experts monitor aneurysm growth over time and track the rate, which is not always consistent from visit to visit. It is possible for a patient's aneurysm to grow 4 centimeters and then remain unchanged for years. Regular monitoring – conducted with ultrasound, CT or MRI imaging, depending upon the aneurysm's location – allows us to evaluate risk and anticipate danger.

Early referral is very important in providing education on the disease process and determining the timing and modality for follow-up care. Our team is happy to monitor any patient, even if his or her scans were taken elsewhere.

Innovative intervention

When intervention does become necessary, our experts may perform traditional open surgery and vessel replacement or may be able to employ innovative, minimally invasive means of aneurysm repair. These minimally invasive operations, increasingly applied, may include:

  • Stent graft placement to reline arteries to exclude flow to the aneurysm. In this procedure, a delivery catheter is used to guide a stent graft through the aneurysm, where it expands upon release to fit the vessel above and below the aneurysm.

  • Coil embolization to close the dilated artery. In this procedure, the catheter is used to place a small metal coil at the site of the aneurysm. The coil is used to seal off the aneurysm.

Sometimes a combination of traditional and endovascular surgery is required to resolve complex aneurysms.

The multidisciplinary advantage

For patients who require intervention to repair complex aneurysms, The University of Kansas Health System offers an important advantage. Because aneurysms can occur in any part of the body and involve any organs connected to the vessel containing the aneurysm, experts in multiple specialties may play a role to ensure the best outcomes for patients. We offer expertise across disciplines and work collaboratively to bring patients the benefits of our distinct specialty training. Consider, for example:

  • Recently, a patient presented with changes in the quality of her voice. She was evaluated by an otolaryngologist and a neurointerventional radiologist. When surgical repair was decided upon, a neurosurgeon and vascular surgeon teamed to perform a bypass from the neck to the intracranial arteries and allow safe ligation of the large aneurysm at the skull base. A cardiothoracic surgeon retrieved the radial artery bypass conduit.

  • In another case, our team prepared to correct a distal renal artery aneurysm in a patient who had only one kidney. Given the increased risk, we engaged with a transplant surgeon and urologist to provide immediate support in the event of complications that could compromise the function of the remaining kidney.

Many aneurysms require only a vascular surgeon's focus. But when complex cases demand the attention of diverse specialists, our cooperative approach and comprehensive team ensure every patient receives the attention of every relevant expert. We conduct a multidisciplinary vascular conference in which we present cases in front of numerous specialists to solicit recommendations on the best treatment approach. We direct patient care to the most appropriate specialist or specialists based on the location and potential impact of the aneurysm.

It is our commitment to apply the right expertise and the best experience to evaluate each aneurysm and identify the most effective and safest means to repair it.

Balancing risks

While the intervention often averts life-threatening aneurysm rupture, it is not without risks. It is important to understand the concerns and evaluate the risks of monitoring versus repairing when making decisions for each patient. Bleeding, infection, vascular injury and renal complications may occur in conjunction with surgery.

The location of the aneurysm, including proximity to vital branches, will determine whether endovascular intervention is a feasible alternative to traditional surgical reconstruction. Endovascular exclusion is often performed through a puncture in the femoral artery. This minimally invasive approach usually entails an overnight hospital stay followed by several days of reduced activity in comparison with the several-day hospital stay associated with traditional surgery.

The importance of awareness

Because most aneurysms have no symptoms that warn of their presence, awareness is critical in determining when specialty care is advisable. Some large aneurysms of the abdomen or extremities may be detectable upon physical exam. Others are discovered incidentally on imaging studies performed for other medical problems. Abdominal aortic aneurysms may be detected on a screening ultrasound in patients who are at increased risk (>65 years of age, history of smoking, hypertension, male).

Our team collaborates with referring physicians to provide preventive and corrective care. We evaluate patients individually to devise personalized schedules for monitoring visits, often every 6 to 12 months until aneurysm growth rates suggest more frequent oversight is appropriate.

Until then, a focus on smoking cessation and blood pressure control is the best protection against complex aneurysm.

Dr. Kirk Hance, RPVI, is the division chief for vascular surgery at The University of Kansas Health System and serves as a clinical assistant professor at the University of Kansas Medical Center. His clinical practice focuses on vascular surgery, aneurysm surgery and endovascular surgery.